Hhs 5161-1

HHS Supplemental Form to the SF-424 (HHS 5161-1)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0317 can be found here:

Documents and Forms

Document Name Document Type
Form HHS 5161-1 HHS 5161-1 Form and Instruction
HHS 5161-1 HHS 5161-1 HHS-5161-1_with corrections (Final) 8-30-10 ver1.doc Form and Instruction

Information Collection (IC) Details

IC Title:	HHS 5161-1	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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	HHS 5161-1	HHS 5161-1	HHS-5161-1_with corrections (Final) 8-30-10 ver1.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,457	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	7,457	7,457
Annual IC Time Burden (Hours)	42,691	42,691
Annual IC Cost Burden (Dollars)	0	0

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.