Information Collection

Data Entry Form

IC 268981 under ICR 202406-0920-005 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Data Entry Form	Form
Data Entry Form Att C - OD2A LOCAL LTC Data Entry Form.pdf	Form
Data Entry Form Att C - OD2A LOCAL LTC Data Entry Form.pdf	Form
OMB Control Header and Burden Statement for AttC.docx Data Entry Form	IC Document
OMB Control Header and Burden Statement for AttC.docx Data Entry Form	IC Document

IC Title:

Data Entry Form

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 Entry Form	Att C - OD2A LOCAL LTC Data Entry Form.pdf		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)	48	48
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Data Entry Form	OMB Control Header and Burden Statement for AttC.docx	06/25/2024

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