Information Collection

51.25(b)(3)

IC 192380 under ICR 201003-0930-004 · OMB 0930-0172.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0172 can be found here:

Documents and Forms

Document Name Document Type
Form Statement 51.25(b)(3) Form
Statement Statement There are no instruments to this data collection.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	51.25(b)(3)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 51.PAIMI

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Statement	Statement	There are no instruments to this data collection.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 57	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 45 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	57	-85	142
Annual IC Time Burden (Hours)	29	-156	185
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.