Information Collection

Cli

IC 214493 under ICR 201610-0930-001 · OMB 0930-0348.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CLI CLI	Form and Instruction
CLI CLI Attachment2 PFS_CLI_FINAL_OMB_10-1-2014.doc	Form and Instruction

IC Title:

CLI

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 and Instruction	CLI	CLI	Attachment2 PFS_CLI_FINAL_OMB_10-1-2014.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 786

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,364	330	1,034
Annual IC Time Burden (Hours)	3,546	858	2,688
Annual IC Cost Burden (Dollars)	0	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.