Information Collection

Community Member - Adult

IC 193427 under ICR 201006-0930-003 · OMB 0930-0315.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Community_Adult_In Community Member - Adult	Form and Instruction
Community_Adult_In Community_Adult_Instruments Attachment 9-Community_Adult_Instruments.pdf	Form and Instruction
Attachment 10-Community_Adult_Supporting.pdf Community_Adult_Supporting	IC Document

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	Community_Adult_Instruments	Community_Adult_Instruments	Attachment 9-Community_Adult_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: 2,234

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	2,234	2,234
Annual IC Time Burden (Hours)	1,676	1,676
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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

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