Information Collection

EHE Triannual Module OMB Mockup

IC 240018 under ICR 202002-0906-002 · OMB 0906-0051.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0051 can be found here:

Documents and Forms

Document Name Document Type
Form 1 EHE Triannual Module OMB Mockup Form
1 EHE Triannual Module_OMB mockup - FORM.docx EHE Triannual Module_OMB mockup - FORM.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	EHE Triannual Module OMB Mockup	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	1	EHE Triannual Module_OMB mockup - FORM.docx	EHE Triannual Module_OMB mockup - 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: 942	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	2,826	2,826
Annual IC Time Burden (Hours)	5,087	5,087
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.