Information Collection

State/Local/Tribal Sector - Special Data Reporting

IC 214567 under ICR 201612-0920-001 · OMB 0920-1053.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
State/Local/Tribal Sector - Special Data Reporting	Form
Special Data Request Att 4_Special Data Request.docx	Form

IC Title:

State/Local/Tribal Sector - Special Data Reporting

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:

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	Special Data Request	Att 4_Special Data Request.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 41

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	41	41
Annual IC Time Burden (Hours)	246	246
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.