Information Collection

Hhs 5161-1

IC 180307 under ICR 201701-0930-001 · OMB 0930-0367.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0367 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5161 HHS 5161-1	Form
5161 Checklist_Narrative 0990-0317_5161-SS-A_B.pdf	Form

IC Title:

HHS 5161-1

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	5161	Checklist_Narrative	0990-0317_5161-SS-A_B.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,457

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	7,457	0	7,457
Annual IC Time Burden (Hours)	19,930	-22,761	42,691
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.