Information Collection

Needs Assessment

IC 184799 under ICR 200805-0935-001 · OMB 0935-0137.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 Needs Assessment	Form and Instruction
Form #1 Needs Assessment Attachment C_DRAFT Needs Assessment Revised_v4.doc	Form and Instruction

IC Title:

Needs Assessment

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 and Instruction	Form #1	Needs Assessment	Attachment C_DRAFT Needs Assessment Revised_v4.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.