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 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				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		09/21/2009

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

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