Information Collection

Attachment D_Additional Data Elements

IC 261604 under ICR 202603-0915-002 · OMB 0915-0298.

Documents and Forms

Document Name Document Type
Form 3 DGIS OMB_SSA_Attachment D_Additional Data Elements_2026_03172026 Attachment D_Additional Data Elements Form and Instruction
3 DGIS OMB_SSA_Attachment D_Additional Data Elements_2026_ DGIS OMB_SSA_Attachment D_Additional Data Elements_2026_03172026.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Attachment D_Additional Data Elements	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	DGIS OMB_SSA_Attachment D_Additional Data Elements_2026_03172026	DGIS OMB_SSA_Attachment D_Additional Data Elements_2026_03172026.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 578	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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	578	578
Annual IC Time Burden (Hours)	1,463	1,463
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].