Information Collection

Recipient Information

IC 243520 under ICR 202401-0920-007 · OMB 0920-0106.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0106 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Recipient Information	Form and Instruction
Recipient Information Instruments Att D_Recipient Information Instruments_050120.docx	Form and Instruction
Recipient Information Instruments Att D_Recipient Information Instruments_050120.docx	Form and Instruction

IC Title:

Recipient Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	none	Recipient Information Instruments	Att D_Recipient Information Instruments_050120.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 61

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
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-61	61
Annual IC Time Burden (Hours)	-122	122
Annual IC Cost Burden (Dollars)	-4,204	4,204

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.