Information Collection

Annual Updates

IC 43630 under ICR 201211-0925-004 · OMB 0925-0522.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0522 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Annual Updates	Form and Instruction
1 SIS_OMB_2012_WebScreenShots_20121024 Att 12 SIS_OMB_2012_WebScreenShots_20121024 Att 12.pdf	Form and Instruction
1 SIS_Annual_Forms_20121018_Att 1A SIS_Annual_Forms_20121018_Att 1A.pdf	Form and Instruction
SIS_Annual_Correspondence_20121018_Att 1B.pdf SIS_Annual_Correspondence_20121018_Att 1B.pdf	IC Document

IC Title:

Annual Updates

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	1	SIS_OMB_2012_WebScreenShots_20121024 Att 12	SIS_OMB_2012_WebScreenShots_20121024 Att 12.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	1	SIS_Annual_Forms_20121018_Att 1A	SIS_Annual_Forms_20121018_Att 1A.pdf		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 33,923

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 20 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	33,923	-66,077	100,000
Annual IC Time Burden (Hours)	5,654	-2,846	8,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SIS_Annual_Correspondence_20121018_Att 1B.pdf	SIS_Annual_Correspondence_20121018_Att 1B.pdf	01/22/2013

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