PHHS Block Grant Management Information System (BG-MIS) Annual Report

Preventive Health and Health Services Block Grant

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0106 can be found here:

Documents and Forms

Document Name Document Type
Attach 5A Annual Report Instrument.doc Other-WORD
Attach 5B Annual Report Guidance.doc Att 5B Work Plan Guidance IC Document
Attach 5C Annual Report Guidance Updates.docx Att 5C Summary of Changes IC Document

Information Collection (IC) Details

IC Title:	PHHS Block Grant Management Information System (BG-MIS) Annual Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			Attach 5A Annual Report Instrument.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 61	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	61	0	61
Annual IC Time Burden (Hours)	915	-915	1,830
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Att 5B Work Plan Guidance	Attach 5B Annual Report Guidance.doc	06/01/2011
Att 5C Summary of Changes	Attach 5C Annual Report Guidance Updates.docx	06/01/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.