Information Collection

Contacts, Locations and Reportable Conditions

IC 198343 under ICR 201710-0970-003 · OMB 0970-0427.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0427 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Contacts, Locations and Reportable Conditions	Form and Instruction
1 Contacts Instrument-Contacts.pdf	Form and Instruction
1 Center Location Instrument-Center Locations.pdf	Form and Instruction
1 Reportable Conditions Instrument-Reportable Conditions.pdf	Form and Instruction

IC Title:

Contacts, Locations and Reportable Conditions

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 1300

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Contacts	Instrument-Contacts.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Center Location	Instrument-Center Locations.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	1	Reportable Conditions	Instrument-Reportable Conditions.pdf	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,267

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

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	3,267	226	3,041
Annual IC Time Burden (Hours)	817	57	760
Annual IC Cost Burden (Dollars)	0	0	0

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.