Information Collection

State and Local HD Staff Form 1 part B

IC 276632 under ICR 202507-0920-014 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
State and Local HD Staff Form 1 part B	Form and Instruction
Form 1 Medical Tourism Case Intake Form State and Local HD Staff Form 1 part B	Form and Instruction
Form 1 Medical Tourism Case Intake Form Att. C - Form 1 Medical Tourism Case Intake Form_0625final_v2.docx	Form and Instruction
Form 1 Medical Tourism Case Intake Form Att. C - Form 1 Medical Tourism Case Intake Form_0625final_v2.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-24HD

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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	750	750
Annual IC Time Burden (Hours)	63	63
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.

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