Information Collection

Section 1115 Demonstration, HIV and AIDS Application Template

IC 198610 under ICR 201107-0938-010 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
HIV SMDL - Demo Template-042111 [rev 07-18-11].pdf	Other-Application Template

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
Other-Application Template			HIV SMDL - Demo Template-042111 [rev 07-18-11].pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6	6
Annual IC Time Burden (Hours)	270	270
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.