Information Collection

Contact Information

IC 232931 under ICR 202010-0920-005 · OMB 0920-1246.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Contact Information	Form
TLC Contact Information Att 4b_TLC Contact Information_23Aug2018.docx	Form

IC Title:

Contact Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

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	n/a	TLC Contact Information	Att 4b_TLC Contact Information_23Aug2018.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems HHS/CDC

FR Citation: 57 FR 62812

Number of Respondents: 75

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	122	122

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.