Information Collection

Input Record

IC 179584 under ICR 201603-0970-001 · OMB 0970-0161.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0161 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Input Record	Form
1 Input Record Specifications Input_Record_Specifications_(E_Charts) FINAL.docx	Form

IC Title:

Input Record

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	1	Input Record Specifications	Input_Record_Specifications_(E_Charts) FINAL.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Location and Collection system

FR Citation: 78 FR 5812

Number of Respondents: 54

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 99 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,808	2,808
Annual IC Time Burden (Hours)	842	842
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.