SE Service Providers

Community Support Evaluation

Documents and Forms

Document Name Document Type
Form SSA KII Service Pr SE Service Providers Form and Instruction
SSA KII Service Pr SSA KII Service Provider Version Attachment M_SSA KII Service Provider Version (Y2-Y4).docx Form and Instruction

Information Collection (IC) Details

IC Title:	SE Service Providers	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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	SSA KII Service Provider Version	SSA KII Service Provider Version	Attachment M_SSA KII Service Provider 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 %

	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

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.