Information Collection

Follow-Up (triennial)

IC 190833 under ICR 201602-0925-013 · OMB 0925-0522.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Follow-Up (triennial)	Form and Instruction
2 Attachment 2d Follow-up WebScreen shot SISOMB2016ATTACHMENT2dFollowUpWebScreenShots20160219.pdf	Form and Instruction
SISOMB2016ATTACHMENT2aFOLLOWUPform20160219.pdf Attachment 2A FollowUp Form	IC Document
SISOMB2016ATTACHMENT2bFOLLOWUPcorrespondence20160219.pdf Attachment 2b FollowUp Correspondence	IC Document

IC Title:

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	2	Attachment 2d Follow-up WebScreen shot	SISOMB2016ATTACHMENT2dFollowUpWebScreenShots20160219.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,108

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	16,108	-853	16,961
Annual IC Time Burden (Hours)	10,739	-10,462	21,201
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 2A FollowUp Form	SISOMB2016ATTACHMENT2aFOLLOWUPform20160219.pdf	02/22/2016
Attachment 2b FollowUp Correspondence	SISOMB2016ATTACHMENT2bFOLLOWUPcorrespondence20160219.pdf	02/22/2016

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