Information Collection

Pilot Participation Form

IC 221212 under ICR 201603-4040-001 · OMB 4040-0017.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

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-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 %

table that charts list of burden
	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

table that charts IC Documents
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.