Information Collection

SAMHSA/CSAT's Viral Hepatitis Information Form

IC 188545 under ICR 201212-0930-001 · OMB 0930-0300.

Documents and Forms

Document Name Document Type
Form Hepatitis Reportin SAMHSA/CSAT's Viral Hepatitis Information Form Form
0300-Public Burden Statement.doc Instruction
Hepatitis Reportin Hepatitis Reporting Form Attachment A. 3-14-13.docx Form
Attachment B. 3-14-13.docx Project Management IT/Database Design Plan IC Document

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Hepatitis Reporting Form	Hepatitis Reporting Form	Attachment A. 3-14-13.docx		Yes	Yes	Fillable Printable
Instruction			0300-Public Burden Statement.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 800	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	40	40
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Project Management IT/Database Design Plan	Attachment B. 3-14-13.docx	03/19/2013

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