Information Collection

42 CFR 50.605(a)(4) (Disclosure)

IC 200600 under ICR 201809-0925-001 · OMB 0925-0417.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0417 can be found here:

Documents and Forms

Document Name Document Type
Attach 4 - Instructions (3).doc Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	42 CFR 50.605(a)(4) (Disclosure)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 50.605(a)(4)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Attach 4 - Instructions (3).doc		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 992	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	992	42	950
Annual IC Time Burden (Hours)	11,904	504	11,400
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.