Information Collection

ATR Evaluation

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.