Information Collection

Alzheimer's Disease Supportive Services Program (ADSSP) Data Collection

IC 178976 under ICR 202310-0985-003 · OMB 0985-0022.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Alzheimer's Disease Supportive Services Program (ADSSP) Data Collection	Form and Instruction
0022 PRA Public Burden Statement.pdf	Other-PRA PBS
0022 PRA Public Burden Statement.pdf	Other-PRA PBS
ADSSP Excel Tool 0022 Final Ins.xlsx	Form and Instruction
ADSSP Excel Tool 0022 Final Ins.xlsx	Form and Instruction

IC Title:

Agency IC Tracking Number:

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	NA	ADSSP Excel Tool	0022 Final Ins.xlsx		Yes	Yes	Fillable Fileable
Other-PRA PBS			0022 PRA Public Burden Statement.pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 69

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	138	-402	540
Annual IC Time Burden (Hours)	916	-1,413	2,329
Annual IC Cost Burden (Dollars)	0	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.