State/Local/Tribal Sector-Initial population

Monitoring and Reporting System for the Division of Community Health's Cooperative Agreement Programs

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1053 can be found here:

Documents and Forms

Document Name Document Type
State/Local/Tribal Sector-Initial population Form
DCH screenshots Att3a_DCH-PMD Screen Shots_3 14 16.docx Form

Information Collection (IC) Details

IC Title:	State/Local/Tribal Sector-Initial population	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	DCH screenshots	Att3a_DCH-PMD Screen Shots_3 14 16.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	14	14
Annual IC Time Burden (Hours)	210	210
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.