Information Collection

Contacts, Locations and Reportable Conditions

IC 198343 under ICR 201106-0980-003 · OMB 0980-0017.

Documents and Forms

Document Name Document Type
Form 1 Contacts, Locations and Reportable Conditions Form and Instruction
1 Contacts Contacts page in Edit mode.pdf Form and Instruction
1 Center Location Center Locations.pdf Form and Instruction
1 Reportable Conditions Reportable Conditions.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Contacts, Locations and Reportable Conditions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 1300

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Contacts	Contacts page in Edit mode.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Center Location	Center Locations.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Reportable Conditions	Reportable Conditions.pdf	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,690	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,690	2,690
Annual IC Time Burden (Hours)	673	673
Annual IC Cost Burden (Dollars)	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.