Information Collection

Data Import Template

IC 268980 under ICR 202406-0920-005 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.