Information Collection

Title V Survey

IC 208301 under ICR 201308-0915-003 · OMB 0915-0369.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Title V Survey	Form and Instruction
1 survey Title V Survey.docx	Form and Instruction
5.a. Prenotification E-mail_mr.docx 5	IC Document
5.b. Cover E-mail_mr.docx 5	IC Document
5.e. Reminder Email_mr.docx 5	IC Document

IC Title:

Title V Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	survey	Title V Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 52

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	52	52
Annual IC Time Burden (Hours)	1,872	1,872
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
5	5.a. Prenotification E-mail_mr.docx	07/31/2013
5	5.b. Cover E-mail_mr.docx	07/31/2013
5	5.e. Reminder Email_mr.docx	07/31/2013

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