Information Collection

Service Providers

IC 193426 under ICR 201006-0930-003 · OMB 0930-0315.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Service_Provider_I Service Providers	Form and Instruction
Service_Provider_I Service_Provider_Instruments Attachment 7-Service_Provider_Instruments.pdf	Form and Instruction
Attachment 8-Service_Provider_Supporting.pdf Service_Provider_Supporting	IC Document

IC Title:

Service Providers

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	Service_Provider_Instruments	Service_Provider_Instruments	Attachment 7-Service_Provider_Instruments.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 378

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
Annual Number of Responses for this IC	378	378
Annual IC Time Burden (Hours)	756	756
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Service_Provider_Supporting	Attachment 8-Service_Provider_Supporting.pdf	06/10/2010

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