Information Collection

State Government or Qualified State- Full biannual report

IC 195395 under ICR 201208-0955-008 · OMB 0955-0008.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

State Government or Qualified State- Full biannual report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 412 42 CFR 413 42 CFR 422 42 CFR 495

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

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	112	112
Annual IC Time Burden (Hours)	1,344	1,344
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.