Information Collection

Financial Mapping Interview

IC 226024 under ICR 201703-0930-004 · OMB 0930-0375.

Documents and Forms

Document Name Document Type
Form Financing Plan Sur Financial Mapping Interview Form and Instruction
Financing Plan Sur Financing Plan Survey and Interviews Attachment 5 CMHI Financing Plan Survey and Interviews 10-06-2016.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Financial Mapping Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 and Instruction	Financing Plan Survey and Interviews	Financing Plan Survey and Interviews	Attachment 5 CMHI Financing Plan Survey and Interviews 10-06-2016.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 225	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	225	225
Annual IC Time Burden (Hours)	95	95
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.