Recipient Information

[PHIC] Preventive Health and Health Services Block Grant

Documents and Forms

Document Name Document Type
Recipient Information Form and Instruction
Recipient Information Instruments Att D_Recipient Information Instruments_050120.docx Form and Instruction
Recipient Information Instruments Att D_Recipient Information Instruments_050120.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Recipient Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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
Form and Instruction	none	Recipient Information Instruments	Att D_Recipient Information Instruments_050120.docx		Yes	Yes	Fillable Fileable

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 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-61	61
Annual IC Time Burden (Hours)	-122	122
Annual IC Cost Burden (Dollars)	-4,204	4,204

Documents for IC

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.