Information Collection

Attachment 12 DDT MIS Add Surveillance Sources Screen

IC 178776 under ICR 201003-0920-011 · OMB 0920-0479.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
DDT MIS Add Surveillance Sources Attachment 12 DDT MIS Add Surveillance Sources Screen	Form
DDT MIS Add Surveillance Sources Attachment 12 DDT MIS Add Surveillance Sources.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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 Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 59

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
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-59	59
Annual IC Time Burden (Hours)	-590	590
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.

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