Information Collection

ATSDR Success Story Form

IC 226338 under ICR 202309-0923-001 · OMB 0923-0057.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ATSDR Success Story Form	Form and Instruction
Success Story Form (screenshots) Att4d ATSDR Success Story Form 09132023v2.pdf	Form and Instruction
Success Story Form (screenshots) Att4d ATSDR Success Story Form 09132023v2.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

17IV

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	n/a	Success Story Form (screenshots)	Att4d ATSDR Success Story Form 09132023v2.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

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	120	8	112
Annual IC Time Burden (Hours)	60	4	56
Annual IC Cost Burden (Dollars)	0	-2,089	2,089

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.