PFS Supplemental

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0354 can be found here:

Documents and Forms

Document Name Document Type
Form PFS Supplemental PFS Supplemental Form and Instruction
PFS Supplemental PFS Supplemental DSP MRT Attachment _2 PFS Revised (1).docx Form and Instruction
PFS Supplemental PFS Supplemental DSP MRT Attachment _2 PFS Revised (1).docx Form and Instruction

Information Collection (IC) Details

IC Title:	PFS 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	PFS Supplemental	PFS Supplemental	DSP MRT Attachment _2 PFS Revised (1).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: PFS Supplemental	FR Citation: 75 FR 28264

Number of Respondents: 253	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	253	182	71
Annual IC Time Burden (Hours)	253	40	213
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.