Att 5b_ATSDR Technical Assistance (TA) Activity Form

APPLETREE Performance Measures

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0057 can be found here:

Documents and Forms

Document Name Document Type
Att5b ATSDR TA Form 20170310.pdf Other-PDF

Information Collection (IC) Details

IC Title:	Att 5b_ATSDR Technical Assistance (TA) Activity Form	Agency IC Tracking Number:	17IV

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
Other-PDF			Att5b ATSDR TA Form 20170310.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25	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	375	375
Annual IC Time Burden (Hours)	32	32
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.