Information Collection

Attachment C Program Specific Form

IC 261602 under ICR 202404-0915-004 · OMB 0915-0298.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0298 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Attachment C Program Specific Form	Form and Instruction
Form 2 Attachment C Program Specific Form	Form and Instruction
2 Attachment C Program Specific Form DGIS OMB_SSA_Attachment C_Program Specific Forms_CLEAN HS11 update 07062023.docx	Form and Instruction
2 Attachment C Program Specific Form DGIS OMB_SSA_Attachment C_Program Specific Forms_CLEAN HS11 update 07062023.docx	Form and Instruction

IC Title:

Attachment C Program Specific Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	2	Attachment C Program Specific Form	DGIS OMB_SSA_Attachment C_Program Specific Forms_CLEAN HS11 update 07062023.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,019

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,019	2,019
Annual IC Time Burden (Hours)	1,376	1,376
Annual IC Cost Burden (Dollars)	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.