Pilot Participation Form

DATA Act Section 5 Grants Pilot

Documents and Forms

Document Name Document Type
HHS DAP Section 5 Grants Pilot _Pilot Participation Form_04082016_v2 (2).docx Other-form
4040-0017_Short Supporting Statement Pilot Participation Form_April2016_v2.docx mini supporting st IC Document
PPF Cover Email_04212016.docx email IC Document
4040-0017_SupportingStatementAforPPFICR_April2016_v2.docx Support statement A IC Document

Information Collection (IC) Details

IC Title:	Pilot Participation Form	Agency IC Tracking Number:

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
Other-form			HHS DAP Section 5 Grants Pilot _Pilot Participation Form_04082016_v2 (2).docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,076	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,076	1,076
Annual IC Time Burden (Hours)	269	269
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
mini supporting st	4040-0017_Short Supporting Statement Pilot Participation Form_April2016_v2.docx	04/21/2016
email	PPF Cover Email_04212016.docx	04/21/2016
Support statement A	4040-0017_SupportingStatementAforPPFICR_April2016_v2.docx	04/21/2016

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