Information Collection

ATR Evaluation

IC 187249 under ICR 200811-0930-003 · OMB 0930-0299.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachment 3 - Cli ATR Evaluation	Form and Instruction
Attachment 3 - Cli Attachment 3 - Client Survey Attachment 3_Client Survey.doc	Form and Instruction
Attachment 4 - Pro Attachment 4 - Provider Survey Attachment 4_Provider Survey.doc	Form and Instruction
ATR_OMB Package_10-2008.zip Attachments 1-2, 5-12	IC Document

IC Title:

ATR Evaluation

Agency IC Tracking Number:

Is this a Common Form? Yes

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	Attachment 3 - Client Survey	Attachment 3 - Client Survey	Attachment 3_Client Survey.doc		Yes	Yes	Paper Only
Form and Instruction	Attachment 4 - Provider Survey	Attachment 4 - Provider Survey	Attachment 4_Provider Survey.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11,412

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	11,412	11,412
Annual IC Time Burden (Hours)	3,141	3,141
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachments 1-2, 5-12	ATR_OMB Package_10-2008.zip	11/12/2008

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