Information Collection

Att C_NAMCS CLAS Questionnaire

IC 221651 under ICR 201605-0920-014 · OMB 0920-1119.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att C - Questionnaire 040416.pdf	Other-WORD

IC Title:

Agency IC Tracking Number:

15BCU

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
Other-WORD			Att C - Questionnaire 040416.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0167 Health Resources Utilization Statistics

FR Citation: 49 FR 37697

Number of Respondents: 2,400

Number of Respondents for Small Entity: 336

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 4 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	600	600
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.