State/Local/Tribal Sector - Special Data Reporting

Monitoring and Reporting System for the Division of Community Health's Cooperative Agreement Programs

Documents and Forms

Document Name Document Type
State/Local/Tribal Sector - Special Data Reporting Form
Special Data Request Att 4_Special Data Request.docx Form

Information Collection (IC) Details

IC Title:	State/Local/Tribal Sector - Special Data 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	Special Data Request	Att 4_Special Data Request.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: 50 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	18	-23	41
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.