Information Collection

EHE Expenditures Report

IC 242547 under ICR 202103-0915-001 · OMB 0915-0318.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0318 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 EHE Expenditures Report	Form and Instruction
5 EHE Allocations and Expenditures CLEAN.docx EHE Allocations and Expenditures CLEAN.docx	Form and Instruction
5 EHE Allocations and Expenditures CLEAN.docx EHE Allocations and Expenditures CLEAN.docx	Form and Instruction

IC Title:

EHE Expenditures Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	5	EHE Allocations and Expenditures CLEAN.docx	EHE Allocations and Expenditures CLEAN.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 47

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	Previously Approved
Annual Number of Responses for this IC	47	47
Annual IC Time Burden (Hours)	188	188
Annual IC Cost Burden (Dollars)	0	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.