Information Collection

Attachment D

IC 261604 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⚠️ Notice: This information collection may be referencing outdated material.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 3 Attachment D	Form and Instruction
Form 3 Attachment D	Form and Instruction
3 Attachment D Additional Data Elements DGIS OMB_SSA_Attachment D_Additional Data Elements_CLEAN_HS Site Form Update.docx	Form and Instruction
3 Attachment D Additional Data Elements DGIS OMB_SSA_Attachment D_Additional Data Elements_CLEAN_HS Site Form Update.docx	Form and Instruction

IC Title:

Attachment D

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	3	Attachment D Additional Data Elements	DGIS OMB_SSA_Attachment D_Additional Data Elements_CLEAN_HS Site Form Update.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 578

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	578	578
Annual IC Time Burden (Hours)	1,463	1,463
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.