Information Collection

Web-based Data Collection Form

IC 192521 under ICR 201004-0915-001 · OMB 0915-0332.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 004 - ECCS Web-based Data Collection Form	Form and Instruction
004 - ECCS Attachment D - Indicator Reporting Form Attachment D Indicator Reporting Form_revised June 4 10.doc.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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 and Instruction	004 - ECCS	Attachment D - Indicator Reporting Form	Attachment D Indicator Reporting Form_revised June 4 10.doc.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 52

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	52	52
Annual IC Time Burden (Hours)	78	78
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.