SPF-Rx Supplemental

Division of State Programs—Management Reporting Tool (DSP-MRT)

Documents and Forms

Document Name Document Type
Form SPF-RX SPF-Rx Supplemental Form and Instruction
SPF-RX SPF-RX DSP MRT Attachment _4 SPF-Rx _No changes.docx Form and Instruction
SPF-RX SPF-RX DSP MRT Attachment _4 SPF-Rx _No changes.docx Form and Instruction

Information Collection (IC) Details

IC Title:	SPF-Rx Supplemental	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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	SPF-RX	SPF-RX	DSP MRT Attachment _4 SPF-Rx _No changes.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: SPF-RX	FR Citation: 75 FR 28264

Number of Respondents: 26	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	Previously Approved
Annual Number of Responses for this IC	104	4	100
Annual IC Time Burden (Hours)	104	4	100
Annual IC Cost Burden (Dollars)	0	0	0

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.