Information Collection

Uniform BG Application Amendment

IC 224633 under ICR 201611-0930-001 · OMB 0930-0370.

Documents and Forms

Document Name Document Type
Form Application Uniform BG Application Amendment Form and Instruction
Application Application TAB A FY_2016-2017_SABG__Plan_SSP_Amendment 09152016.docx Form and Instruction
TAB B NASADAD _04-02-2014.pdf Guidance Naloxone IC Document
TAB C hhs-ssp-guidance.pdf Guidance SSP IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Uniform BG Application Amendment	Agency IC Tracking Number:

Is this a Common Form? No		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
Form and Instruction	Application	Application	TAB A FY_2016-2017_SABG__Plan_SSP_Amendment 09152016.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	2,400	2,400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Guidance Naloxone	TAB B NASADAD _04-02-2014.pdf	11/29/2016
Guidance SSP	TAB C hhs-ssp-guidance.pdf	11/29/2016

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