Information Collection

Monthly Data Report Form for Bacterial Specimen Testing

IC 239435 under ICR 201912-0920-013 · OMB 0920-1310.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1310 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-19AYV Monthly Data Report Form for Bacterial Specimen Testing	Form and Instruction
0920-19AYV Monthly Data Report Form for Bacterial Specimen Testing Attachment 3c Form 3 Monthly Data Report Form for Bacterial Specimen Testing.docx	Form and Instruction

IC Title:

Monthly Data Report Form for Bacterial Specimen Testing

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	0920-19AYV	Monthly Data Report Form for Bacterial Specimen Testing	Attachment 3c Form 3 Monthly Data Report Form for Bacterial Specimen Testing.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 55

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	660	660
Annual IC Time Burden (Hours)	2,640	2,640
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.