Information Collection

State Self-Assessment Review and Report

IC 10062 under ICR 200703-0970-004 · OMB 0970-0223.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0223 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 State Self-Assessment Review and Report	Form and Instruction
1 State Self-Assessment Review and Report SelfAssessmentRecommended Reporting Format.doc	Form and Instruction
SelfAssessmentRecommended Reporting Format OMB.doc Revised IC	IC Document

IC Title:

State Self-Assessment Review and Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 308

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 and Instruction	1	State Self-Assessment Review and Report	SelfAssessmentRecommended Reporting Format.doc		No	No	Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	54	0	54
Annual IC Time Burden (Hours)	216	-208,548	208,764
Annual IC Cost Burden (Dollars)	0	-450,000	450,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Revised IC	SelfAssessmentRecommended Reporting Format OMB.doc	06/16/2007

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