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Att 5A_Annual Report Instrument
Preventive Health and Health Services Block Grant
OMB: 0920-0106
IC ID: 184866
OMB.report
HHS/CDC
OMB 0920-0106
ICR 201906-0920-011
IC 184866
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0106 can be found here:
2024-01-30 - Revision of a currently approved collection
2020-09-14 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
Att E_Annual Report Instrument.pdf
Other-WORD
Att J_AnnualReportGuidance_Final.doc
Att J_AnnualReportGuidance
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Att 5A_Annual Report Instrument
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
Att E_Annual Report Instrument.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
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 New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
61
0
0
0
0
61
Annual IC Time Burden (Hours)
915
0
0
0
0
915
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Att J_AnnualReportGuidance
Att J_AnnualReportGuidance_Final.doc
06/27/2019
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.