Information Collection

Local Implementing Agency and Family Nomination Form

IC 267243 under ICR 202404-0906-005 · OMB 0906-0099.

Documents and Forms

Document Name Document Type
Form 6 Local Implementing Agency and Family Nomination Form Form and Instruction
6 LIA and Family Nomination Form Local Implementing Agency and Family Nomination Form- MCHB- Disparities-.docx Form and Instruction
6 LIA and Family Nomination Form Appendix E_Disparities Instrument 2_LIA and Family Nomination Form 08012024.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Local Implementing Agency and Family Nomination Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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	6	LIA and Family Nomination Form	Appendix E_Disparities Instrument 2_LIA and Family Nomination Form 08012024.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 70	Number of Respondents for Small Entity: 70

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	70	70
Annual IC Time Burden (Hours)	140	140
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.