Information Collection

Client FG

IC 194042 under ICR 201010-0930-001 · OMB 0930-0317.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Client Instruments Client FG	Form and Instruction
Client Instruments Client Instruments Attachment 1A-Client Instruments.pdf	Form and Instruction
Client Instruments Client Instruments Attachment 1B-Client Instrument-cont'd.pdf	Form and Instruction
Attachment 2A-Client Other.pdf Client Other	IC Document
Attachment 2B-Client Other-cont'd.pdf Client Other	IC Document
Attachment 2C-Client Other-cont'd-2.pdf Client Other	IC Document

IC Title:

Client FG

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Client Instruments	Client Instruments	Attachment 1A-Client Instruments.pdf		Yes	Yes	Paper Only
Form and Instruction	Client Instruments	Client Instruments	Attachment 1B-Client Instrument-cont'd.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 240

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	240	240
Annual IC Time Burden (Hours)	240	240
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Client Other	Attachment 2A-Client Other.pdf	10/20/2010
Client Other	Attachment 2B-Client Other-cont'd.pdf	10/20/2010
Client Other	Attachment 2C-Client Other-cont'd-2.pdf	10/20/2010

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