Information Collection

Data Collection Checklist

IC 185554 under ICR 202312-0920-008 · OMB 0920-0621.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0621 Data Collection Checklist	Form and Instruction
Class Participation Form Data Collection Checklist	Form
0920-0621 Class Participation Form 0621 NYTS Att I4 Class Participation Form final.docx	Form and Instruction
Class Participation Form 0621 NYTS Att I4 Class Participation Form final.docx	Form

IC Title:

Agency IC Tracking Number:

0920-0621

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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	n/a				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,497

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,497	320	1,177
Annual IC Time Burden (Hours)	374	79	295
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.

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