Information Collection

Phs Supplements To Standard A-102 Forms

IC 165988 under ICR 197812-0937-005 · OMB 0937-0011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0937-0011 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	PHS SUPPLEMENTS TO STANDARD A-102 FORMS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	PHS 5159	No	No
Form	PHS 5161-1,2	No	No
Form	PHS 5162-1,2	No	No
Form	PHS 5163	No	No
Form	PHS 5164	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,800	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	12,800	8,800	4,000
Annual IC Time Burden (Hours)	16,037	37	16,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.