Information Collection

Needs Assessment

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.