Information Collection

BASE -Injury Indicator

IC 220420 under ICR 201603-0920-003 · OMB 0920-1120.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att E_Injury Indicators.010716.xlsx	Other-WORD
Att E2_Inj Ind Instructions.pdf e2_Injury Indicator Spreadsheet Instructions	IC Document

IC Title:

Agency IC Tracking Number:

16BZ

Is this a Common Form? No

IC Status: New

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
Other-WORD			Att E_Injury Indicators.010716.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

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)	280	280
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
e2_Injury Indicator Spreadsheet Instructions	Att E2_Inj Ind Instructions.pdf	03/03/2016

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