Information Collection

Attachment C Program Specific Form

IC 261602 under ICR 202308-0915-004 · OMB 0915-0298.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0298 can be found here:

Documents and Forms

Document Name Document Type
Form 2 Attachment C Program Specific Form Form and Instruction
2 Attachment C Program Specific Form DGIS OMB_SSA_Attachment C_Program Specific Forms_CLEAN HS11 update 07062023.docx Form and Instruction
2 Attachment C Program Specific Form DGIS OMB_SSA_Attachment C_Program Specific Forms_CLEAN HS11 update 07062023.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Attachment C Program Specific Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

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	2	Attachment C Program Specific Form	DGIS OMB_SSA_Attachment C_Program Specific Forms_CLEAN HS11 update 07062023.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,019	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,019	2,019
Annual IC Time Burden (Hours)	1,376	1,376
Annual IC Cost Burden (Dollars)	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.