Recipient Information

Preventive Health and Health Services Block Grant

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Recipient Information Form and Instruction
Recipient Information Instruments Att D_Recipient Information Instruments_050120.docx Form and Instruction
Recipient Information Instruments Att D_Recipient Information Instruments_050120.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Recipient Information	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 and Instruction	none	Recipient Information Instruments	Att D_Recipient Information Instruments_050120.docx		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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	61	61
Annual IC Time Burden (Hours)	122	122
Annual IC Cost Burden (Dollars)	4,204	4,204

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.