Information Collection

45 CFR 170.523(f) - Collection and Reporting Requirements

IC 193506 under ICR 201208-0990-001 · OMB 0990-0378.

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Information Collection (IC) Details

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IC Title:	45 CFR 170.523(f) - Collection and Reporting Requirements	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 170.523(f)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	312	0	312
Annual IC Time Burden (Hours)	415	103	312
Annual IC Cost Burden (Dollars)	9,500	9,500	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.