Information Collection

ATSDR Success Story Form

IC 226338 under ICR 202004-0923-001 · OMB 0923-0057.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

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.