Information Collection

Component 1 Reporting Template

IC 244060 under ICR 202402-0920-013 · OMB 0920-1329.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1329 Component 1 Reporting Template	Form and Instruction
0920-1329 PS18-1807 Component 1 Surveillance Reporting Template -W Att 3_Component 1 Reporting Template (1-31-20).docx	Form and Instruction
0920-1329 PS18-1807 Component 1 Surveillance Reporting Template -W Att 3_Component 1 Reporting Template (1-31-20).docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-1329

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	0920-1329	PS18-1807 Component 1 Surveillance Reporting Template -Work Plan Status Report	Att 3_Component 1 Reporting Template (1-31-20).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 80

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	160	-80	240
Annual IC Time Burden (Hours)	1,280	-640	1,920
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.