Information Collection

SAMHSA/CSAT's Viral Hepatitis Information Form

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

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
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

IC Title:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.