Information Collection

Component A & B (Initial 6 month submission) - WORKSHEETS

IC 219504 under ICR 201601-0920-002 · OMB 0920-1124.

Documents and Forms

Document Name Document Type
Component A & B (Initial 6 month submission) - WORKSHEETS Form and Instruction
Component A&B Template - Worksheets/Performance Measures Attachment 4A_ADDM Performance Measures Data Collection Tool.xlsx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Component A & B (Initial 6 month submission) - WORKSHEETS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Component A&B Template - Worksheets/Performance Measures	Attachment 4A_ADDM Performance Measures Data Collection Tool.xlsx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
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

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.