Information Collection

Outreach Reporting Form for Chapters and Districts

IC 222088 under ICR 201606-0923-001 · OMB 0923-0041.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0041 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Outreach Reporting Form for Chapters and Districts	Form
Outreach Reporting for Chapters and Districts Attach_13A-Chapter-District Outreach Reporting Form final.xlsx	Form

IC Title:

Outreach Reporting Form for Chapters and Districts

Agency IC Tracking Number:

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
Form	none	Outreach Reporting for Chapters and Districts	Attach_13A-Chapter-District Outreach Reporting Form final.xlsx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances, 09-19-0001

FR Citation: 76 FR 4432

Number of Respondents: 135

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,620	1,620
Annual IC Time Burden (Hours)	135	135
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.