Information Collection

Application

IC 7545 under ICR 201703-0930-005 · OMB 0930-0168.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0168 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form BG\FY 2018-2019 Bl Application	Form and Instruction
BG\FY 2018-2019 Bl BG\FY 2018-2019 Block Grant Application FY 2018-2019 Block Grant Application and Plan.pdf	Form and Instruction
FY18-19MHBG-funding-agreements.pdf BG\FY18-19 MHBG-funding-agreements	IC Document
FY18-19SABG-funding-agreements.pdf BG\FY18-19 SABG-funding-agreements	IC Document
MHBG Report.pdf BG\MHBG Report	IC Document
SABG Report.pdf BG\SABG Report	IC Document
Block Grant comments. docx.docx Comments	IC Document

IC Title:

Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 and Instruction	BG\FY 2018-2019 Block Grant Application	BG\FY 2018-2019 Block Grant Application	FY 2018-2019 Block Grant Application and Plan.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 119

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	119	0	119
Annual IC Time Burden (Hours)	33,374	-4,055	37,429
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
BG\FY18-19 MHBG-funding-agreements	FY18-19MHBG-funding-agreements.pdf	06/02/2017
BG\FY18-19 SABG-funding-agreements	FY18-19SABG-funding-agreements.pdf	06/02/2017
BG\MHBG Report	MHBG Report.pdf	06/02/2017
BG\SABG Report	SABG Report.pdf	06/02/2017
Comments	Block Grant comments. docx.docx	06/02/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.