Information Collection

Att 5A_Annual Report Instrument

IC 184866 under ICR 201906-0920-011 · OMB 0920-0106.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0106 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att E_Annual Report Instrument.pdf	Other-WORD
Att J_AnnualReportGuidance_Final.doc Att J_AnnualReportGuidance	IC Document

IC Title:

Att 5A_Annual Report Instrument

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			Att E_Annual Report Instrument.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 61

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	61	61
Annual IC Time Burden (Hours)	915	915
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att J_AnnualReportGuidance	Att J_AnnualReportGuidance_Final.doc	06/27/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.