Information Collection

Uniform BG Application Amendment

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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 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 %

table that charts list of burden
	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

table that charts IC Documents
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.