Information Collection

State Program Interim Reporting System

IC 7137 under ICR 200910-0920-012 · OMB 0920-0669.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
State Program Interim Reporting System	Form
State Program Interim Reporting Attachment_D_083109.pdf	Form
Attachment_E_Table_of_Data_Revisions_08-14-09.doc Table of Data Revisions	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	none	State Program Interim Reporting	Attachment_D_083109.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	25	-31	56
Annual IC Time Burden (Hours)	250	-422	672
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Table of Data Revisions	Attachment_E_Table_of_Data_Revisions_08-14-09.doc	09/21/2009

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