Information Collection

Administrators

IC 220572 under ICR 201603-0930-004 · OMB 0930-0363.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA KII Administra Administrators	Form and Instruction
SSA KII Administra SSA KII Administrator Version Attachment L_SSA KII Administrator Version (Y2-Y4).docx	Form and Instruction
Attachment Q_SSA KII Verbal Consent Script.docx SSA KII Verbal Consent Script	IC Document

IC Title:

Administrators

Agency IC Tracking Number:

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
Form and Instruction	SSA KII Administrator Version	SSA KII Administrator Version	Attachment L_SSA KII Administrator Version (Y2-Y4).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14

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	14	14
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA KII Verbal Consent Script	Attachment Q_SSA KII Verbal Consent Script.docx	03/10/2016

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