Information Collection

Annual Report

IC 6649 under ICR 201709-0920-007 · OMB 0920-0138.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0138 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Annual Report	Form
Annual Report Attachment D Annual Report.docx	Form

IC Title:

Annual Report

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	N/A	Annual Report	Attachment D Annual Report.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 32

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	32	32
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	352	352

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.