ATSDR Requests Form

[ATSDR] APPLETREE Performance Measures

Documents and Forms

Document Name Document Type
ATSDR Requests Form Form and Instruction
ATSDR Requests for Certified PHAs/HCs Att4j ATSDR Requests Form (ARMSS) (NEW).pdf Form and Instruction
ATSDR Requests for Certified PHAs/HCs Att4j ATSDR Requests Form (ARMSS) (NEW).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	ATSDR Requests Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	n/a	ATSDR Requests for Certified PHAs/HCs	Att4j ATSDR Requests Form (ARMSS) (NEW).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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	90	90
Annual IC Time Burden (Hours)	11	11
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.