Information Collection

Providers Trainees - State/Tribal

IC 178433 under ICR 201512-0930-006 · OMB 0930-0286.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0286 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Provider Trainee I Providers Trainees - State/Tribal	Form and Instruction
Provider Trainee I Provider Trainee Instruments AttachmentsE-1_E-5.pdf	Form and Instruction
Att E-6. TUP-S Consent to Contact (RCT) StateTribal Dec2015.docx TUP-S Consent to Contact (RCT) StateTribal	IC Document

IC Title:

Providers Trainees - State/Tribal

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	Provider Trainee Instruments	Provider Trainee Instruments	AttachmentsE-1_E-5.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,376

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	Previously Approved
Annual Number of Responses for this IC	10,376	6,909	3,467
Annual IC Time Burden (Hours)	3,027	2,632	395
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
TUP-S Consent to Contact (RCT) StateTribal	Att E-6. TUP-S Consent to Contact (RCT) StateTribal Dec2015.docx	12/23/2015

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