Information Collection

PFS Supplemental

IC 232354 under ICR 202109-0930-002 · OMB 0930-0354.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

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.