Information Collection

DSW Report

IC 220379 under ICR 202102-0920-003 · OMB 0920-1129.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
DSW Report	Form
DSW Report O1 DSW Report Screenshot.docx	Form
DSW Report O1 DSW Report Screenshot.docx	Form
E1 DSW Report.docx DSW Report - word	IC Document
E1 DSW Report.docx DSW Report - word	IC Document

IC Title:

DSW Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	none	DSW Report	O1 DSW Report Screenshot.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 90

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-180	180
Annual IC Time Burden (Hours)	-30	30
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
DSW Report - word	E1 DSW Report.docx	03/02/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.