Family-to-Family Health Information Centers Data Submission Form

Family-to-Family Health Information Center (F2F HIC) Feedback Surveys

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.