Information Collection

Ss/hs

IC 184514 under ICR 200804-0930-002 · OMB 0930-0297.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0297 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Instruments SS/HS	Form and Instruction
Instruments Instruments Instruments-Attachments2-8.zip	Form and Instruction
Attachments1and9-13.zip Attachments1and9-13	IC Document

IC Title:

SS/HS

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Instruments	Instruments	Instruments-Attachments2-8.zip		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 106,675

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	106,675	106,675
Annual IC Time Burden (Hours)	16,431	16,431
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachments1and9-13	Attachments1and9-13.zip	03/28/2008

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