Information Collection

State Systems Survey

IC 209768 under ICR 202306-0915-005 · OMB 0915-0335.

Documents and Forms

Document Name Document Type
Form 3 State Systems Survey Form and Instruction
3 State Systems Grantee Survey Attachment D. State Systems Grantee Survey_AT_jpb_5-26-23.docx Form and Instruction
3 State Systems Grantee Survey Attachment D. State Systems Grantee Survey_AT_jpb_5-26-23.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State Systems Survey	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	3	State Systems Grantee Survey	Attachment D. State Systems Grantee Survey_AT_jpb_5-26-23.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5	-3	8
Annual IC Time Burden (Hours)	3	-7	10
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.