ATSDR Success Story Form

APPLETREE Performance Measures

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0057 can be found here:

Documents and Forms

Document Name Document Type
ATSDR Success Story Form Form and Instruction
Att4d Success Story Form_Word 20200325.docx Other-Word document to display instr
Success Story Form Att4d Success Story_SP_Screenshots 20200325.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	ATSDR Success Story Form	Agency IC Tracking Number:	17IV

Is this a Common Form? No		IC Status: Modified

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	n/a	Success Story Form	Att4d Success Story_SP_Screenshots 20200325.pdf		Yes	Yes	Fillable Fileable
Other-Word document to display instrument content			Att4d Success Story Form_Word 20200325.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 28	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	112	12	100
Annual IC Time Burden (Hours)	56	-44	100
Annual IC Cost Burden (Dollars)	2,089	2,089	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.