Hhs 5161-1

HHS Supplemental Form to the SF-424 (HHS 5161-1)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 5161 HHS 5161-1 Form
5161 Checklist_Narrative 0990-0317_5161-SS-A_B.pdf Form

Information Collection (IC) Details

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:

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 %

	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

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.