Information Collection

Weekly Tally Sheet

IC 201609 under ICR 201507-0930-001 · OMB 0930-0270.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0270 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Weekly_Tally_Sheet Weekly Tally Sheet	Form and Instruction
Weekly_Tally_Sheet Weekly_Tally_Sheet 3_20_15_Attachment C_Weekly_Tally_Sheet.docx	Form and Instruction

IC Title:

Weekly Tally Sheet

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	Weekly_Tally_Sheet	Weekly_Tally_Sheet	3_20_15_Attachment C_Weekly_Tally_Sheet.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

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	Previously Approved
Annual Number of Responses for this IC	6,600	6,600
Annual IC Time Burden (Hours)	1,320	1,320
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.