View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Component 1 Reporting Template	Agency IC Tracking Number:	0920-20KN

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD					Yes	Yes	Fillable Fileable
Other-WORD					Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	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	240	0	240	0	0	0
Annual IC Time Burden (Hours)	1,920	0	1,920	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
3B Reporting Template		10/14/2020
3C Reporting Template		10/14/2020

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

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