Information Collection

Ongoing Pricing - State, Local Governments

IC 183490 under ICR 202604-1220-001 · OMB 1220-0039.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachment A CADC Screen Shots Ongoing Pricing - State, Local Governments	Form
Form Attachment H Shuttle Form Ongoing Pricing - State, Local Governments	Form
Attachment A CADC Screen Shots ATT_A_Screen Shots_Collection Instrument for C&S.pdf	Form
Attachment H Shuttle Form ATT_H_Shuttle Form example MC011 Physicians’ Services.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Attachment A			(collected on interviewer's tablet)	Yes	Yes	Fillable Fileable
Form	Attachment H			(submitted via email)	Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 230

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,070	-630	2,700
Annual IC Time Burden (Hours)	683	-208	891
Annual IC Cost Burden (Dollars)	0	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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