Information Collection

Family-to-Family Health Information Centers Data Submission Form

IC 234424 under ICR 201812-0906-001 · OMB 0906-0040.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0040 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Family-to-Family Health Information Centers Data Submission Form	Form and Instruction
1 F2F HIC DataSubmission_Form.docx DataSubmission_Form.docx	Form and Instruction

IC Title:

Family-to-Family Health Information Centers Data Submission Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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 and Instruction	1	F2F HIC DataSubmission_Form.docx	DataSubmission_Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 59

Number of Respondents for Small Entity: 59

Affected Public: Individuals or Households

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	59	59
Annual IC Time Burden (Hours)	5,251	5,251
Annual IC Cost Burden (Dollars)	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.