Information Collection

FTDC Form

IC 198965 under ICR 201506-0930-003 · OMB 0930-0330.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FTDC Form FTDC Form	Form and Instruction
FTDC Form FTDC Form Attachment_A_FDTC_COLLECTION FORM1_2-18-15 (3).doc	Form and Instruction

IC Title:

FTDC Form

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 and Instruction	FTDC Form	FTDC Form	Attachment_A_FDTC_COLLECTION FORM1_2-18-15 (3).doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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	20	20
Annual IC Time Burden (Hours)	320	320
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.