Information Collection

Local context survey (for completion and submission to CDC

IC 271141 under ICR 202409-0920-020 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Local context survey (for completion and submission to CDC	Form and Instruction
Local Context Form Att 5 Local Context Form 08292024_final.docx	Form and Instruction
Local Context Form Att 5 Local Context Form 08292024_final.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-24AH

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 and Instruction	n/a	Local Context Form	Att 5 Local Context Form 08292024_final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 150

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

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	150	150
Annual IC Time Burden (Hours)	300	300
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.