Information Collection

SAMHSA/CSAT's Viral Hepatitis Information Form

IC 188545 under ICR 201207-0930-002 · OMB 0930-0300.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0300 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Hepatitis Reportin SAMHSA/CSAT's Viral Hepatitis Information Form	Form and Instruction
Hepatitis Reportin Hepatitis Reporting Form Hepatitis Reporting Form.doc	Form and Instruction

IC Title:

SAMHSA/CSAT's Viral Hepatitis Information Form

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	Hepatitis Reporting Form	Hepatitis Reporting Form	Hepatitis Reporting Form.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50,000

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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	2,500	2,500
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.