Information Collection

51.25(b)(3)

IC 192380 under ICR 201304-0930-001 · OMB 0930-0172.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0172 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Statement 51.25(b)(3)	Form
Statement Statement There are no instruments to this data collection.doc	Form

IC Title:

51.25(b)(3)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 51.PAIMI

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	Statement	Statement	There are no instruments to this data collection.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 57

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 45 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	57	57
Annual IC Time Burden (Hours)	29	29
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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