Information Collection

State Offices of Rural Health TA Data Collection Form

IC 186810 under ICR 202604-0915-003 · OMB 0915-0322.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Instrument - 0915-0322 - FORHP - SORH Collection Tool - Revision - 04172026.docx State Offices of Rural Health TA Data Collection Form	Form and Instruction
1 Instrument - 0915-0322 - FORHP - SORH Collection Tool - Instrument - 0915-0322 - FORHP - SORH Collection Tool - Revision - 04172026.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

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
	Requested	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	675	675
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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