Information Collection

Contacts, Locations and Reportable Conditions

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

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.