Information Collection

Assessment of Historically Black Colleges and Universities Activities to Eliminate Health Disparities

IC 45007 under ICR 200608-0915-001 · OMB 0915-0303.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form instrument #1 Assessment of Historically Black Colleges and Universities Activities to Eliminate Health Disparities	Form
instrument #1 HBCU survey HBCU Revised Survey.doc	Form
instrument #1 HBCU Survey hbcu tab c.doc	Form
hbcu letter and consent OMB.doc HBCU letter and consent form	IC Document
hbcu tab e.doc HBCU consent form	IC Document
hbcu tab d.doc HBCU Letter	IC Document
hbcu tab f.doc HBCU list	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	instrument #1	HBCU Survey	hbcu tab c.doc		Yes	Yes	Fillable Fileable
Form	instrument #1	HBCU survey	HBCU Revised Survey.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 525

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	525	525
Annual IC Time Burden (Hours)	394	394
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HBCU consent form	hbcu tab e.doc	08/30/2006
HBCU Letter	hbcu tab d.doc	08/30/2006
HBCU list	hbcu tab f.doc	08/30/2006
HBCU letter and consent form	hbcu letter and consent OMB.doc	12/15/2006

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