State Program Interim Reporting System

Monitoring State Nutrition, Physical Activity and Obesity Programs

Documents and Forms

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

Information Collection (IC) Details

IC Title:	State Program Interim Reporting System	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:

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 %

	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

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.