Information Collection

Assessing programmatic efforts and technical assistance needs of WISEWOMAN

IC 196993 under ICR 201008-0920-003 · OMB 0920-0864.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Year 3 Evaluation Survey Part I Assessing programmatic efforts and technical assistance needs of WISEWOMAN	Form
Year 3 Evaluation Survey Part II Assessing programmatic efforts and technical assistance needs of WISEWOMAN	Form
Year 3 Evaluation Survey Part III Assessing programmatic efforts and technical assistance needs of WISEWOMAN	Form
Year 3 Evaluation Survey Part I IC_3_Survey Part I.doc	Form
Year 3 Evaluation Survey Part II IC_3_Survey Part II.doc	Form
Year 3 Evaluation Survey Part III IC_3_Survey Part III.doc	Form
Att 1_IC_3_Screenshot.pdf Att 1: Web Survey Screen Shots (examples)	IC Document
IC_3_Supporting Statement 03 03 2011.docx Supporting Statement	IC Document
Att 2_IC_3_ Introductory Email.doc Att 2: Intro email	IC Document
Att 3_IC_3_ Invitational Email.doc Att 3: Invitation email	IC Document
Att 4_IC_3_ Followup Email.doc Att 4: Reminder email	IC Document
Att 5_IC_3_Thank you Email.doc Att 5: Thank you email	IC Document

IC Title:

Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Year 3 Evaluation Survey Part I	IC_3_Survey Part I.doc	Yes	Yes	Fillable Fileable
Form	none	Year 3 Evaluation Survey Part II	IC_3_Survey Part II.doc	Yes	Yes	Fillable Fileable
Form	none	Year 3 Evaluation Survey Part III	IC_3_Survey Part III.doc	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	63	0	0	0	0	0
Annual IC Time Burden (Hours)	31	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 1: Web Survey Screen Shots (examples)	Att 1_IC_3_Screenshot.pdf	03/17/2011
Supporting Statement	IC_3_Supporting Statement 03 03 2011.docx	03/17/2011
Att 2: Intro email	Att 2_IC_3_ Introductory Email.doc	03/17/2011
Att 3: Invitation email	Att 3_IC_3_ Invitational Email.doc	03/17/2011
Att 4: Reminder email	Att 4_IC_3_ Followup Email.doc	03/17/2011
Att 5: Thank you email	Att 5_IC_3_Thank you Email.doc	03/17/2011

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