Information Collection

Prevention Demonstration Project

IC 190515 under ICR 200908-0990-009 · OMB 0990-0299.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
eoy_instructions_care _and_prevention_doc_final.doc	Instruction
EOY prevention template_final_8-13-09.doc	Other-survey

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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
Instruction			eoy_instructions_care _and_prevention_doc_final.doc		Yes	Yes	Paper Only
Other-survey			EOY prevention template_final_8-13-09.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 25 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	35	35
Annual IC Time Burden (Hours)	2,275	2,275
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.