Information Collection

Retrospective Data Collection

IC 197196 under ICR 201404-0920-003 · OMB 0920-0889.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Shared data elements - screen shots Retrospective Data Collection	Form
Shared data elements - screen shots Att 4a. Traditional Foods SDEs 03222011.pdf	Form
Att 4b. Partner Notification-Shared Data Elements.doc Att 4b - Partner notification data elements	IC Document
Att 4c. Email with Link to SDE.doc Att 4c - Email with SDE link	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

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	none	Shared data elements - screen shots	Att 4a. Traditional Foods SDEs 03222011.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6

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
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-6	6
Annual IC Time Burden (Hours)	-12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 4b - Partner notification data elements	Att 4b. Partner Notification-Shared Data Elements.doc	03/23/2011
Att 4c - Email with SDE link	Att 4c. Email with Link to SDE.doc	03/23/2011

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