Attachment D

Maternal and Child Health Bureau Performance Measures for Discretionary Grant Information System (DGIS)

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.