Information Collection

Data Collection Checklist

IC 185554 under ICR 202203-0920-009 · OMB 0920-0621.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0621 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0621 Data Collection Checklist	Form and Instruction
0920-0621 Data Collection Checklist H1_Data Collection Checklist.docx	Form and Instruction
0920-0621 Data Collection Checklist H1_Data Collection Checklist.docx	Form and Instruction

IC Title:

Data Collection Checklist

Agency IC Tracking Number:

0920-0621

Is this a Common Form? No

IC Status: Unchanged

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	0920-0621	Data Collection Checklist	H1_Data Collection Checklist.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,177

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,177	1,177
Annual IC Time Burden (Hours)	295	295
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.