Information Collection

Request for Information about LIAs

IC 267256 under ICR 202404-0906-005 · OMB 0906-0099.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Request for Information about LIAs	Form and Instruction
1 Request for LIA Request for Information about LIAs- MCHB- Disparities- 4.25.24.docx	Form and Instruction
1 Request for LIA Appendix D_Disparities Instrument 1_Request for Information about LIAs 08012024.docx	Form and Instruction
Appendix D_Disparities Instrument 1_Request for Information about LIAs (RL).docx Appendix D_Disparities Instrument 1_Request for Information about LIAs (RL)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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 and Instruction	1	Request for LIA	Appendix D_Disparities Instrument 1_Request for Information about LIAs 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: 56

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
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix D_Disparities Instrument 1_Request for Information about LIAs (RL)	Appendix D_Disparities Instrument 1_Request for Information about LIAs (RL).docx	08/01/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.