Supplemental Funding for Healthy Communities, Tobacco Control, Diabetes Prevention and Control and Behavioral Risk Factor Surveillance

Communities Putting Prevention to Work

Documents and Forms

Document Name Document Type
Form 3 Supplemental Funding for Healthy Communities, Tobacco Control, Diabetes Prevention and Control and Behavioral Risk Factor Surveillance Form and Instruction
3 Supplemental Funds Application 0920-XXXX Supplemental Funding Application Attch 3.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Supplemental Funding for Healthy Communities, Tobacco Control, Diabetes Prevention and Control and Behavioral Risk Factor Surveillance	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	Supplemental Funds Application	0920-XXXX Supplemental Funding Application Attch 3.doc		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 53	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	53	-8	61
Annual IC Time Burden (Hours)	2,120	-320	2,440
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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