Information Collection

State/Local/Tribal - Semi-annual reporting

IC 214566 under ICR 201802-0920-003 · OMB 0920-1053.

Documents and Forms

Document Name Document Type
State/Local/Tribal - Semi-annual reporting Form
DCH MIS Att3a_DCH-PMD Screen Shots_07 31 2017.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State/Local/Tribal - Semi-annual reporting	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	DCH MIS	Att3a_DCH-PMD Screen Shots_07 31 2017.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18	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	Previously Approved
Annual Number of Responses for this IC	36	-46	82
Annual IC Time Burden (Hours)	108	-138	246
Annual IC Cost Burden (Dollars)	0	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.