Information Collection

Attachment C Program Specific Form

IC 261602 under ICR 202610-0915-002 · OMB 0915-0298.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Attachment C: Program-Specific Forms Attachment C Program Specific Form	Form and Instruction
2 Attachment C: Program-Specific Forms 2. 2026 DGIS-Att-C-Prog-Specific-Forms 0915-0298.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	2				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,680

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
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,680	-339	2,019
Annual IC Time Burden (Hours)	1,021	-355	1,376
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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