Data Import Template

[NCIPC] OD2A: LOCAL Linkage to and Retention in Care Surveillance

Documents and Forms

Document Name Document Type
Data Import Template Form
Data Import Template Att D - OD2A_LOCAL_LTC_Data_Import_Template_Aggregate_v2.xlsx Form
Data Import Template Att D - OD2A_LOCAL_LTC_Data_Import_Template_Aggregate_v2.xlsx Form
OMB Control Header and Burden Statement for AttD.docx OMB Control Header and Burden Statement IC Document
OMB Control Header and Burden Statement for AttD.docx OMB Control Header and Burden Statement IC Document

Information Collection (IC) Details

IC Title:	Data Import Template	Agency IC Tracking Number:	0920-24AZ

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	n/a	Data Import Template	Att D - OD2A_LOCAL_LTC_Data_Import_Template_Aggregate_v2.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	24	24
Annual IC Time Burden (Hours)	192	192
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
OMB Control Header and Burden Statement	OMB Control Header and Burden Statement for AttD.docx	06/25/2024

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