Information Collection

Assessing Programmatic Efforts and Technical Assistance Needs

IC 202746 under ICR 201008-0920-003 · OMB 0920-0864.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Assessing Programmatic Efforts and Technical Assistance Needs	Form and Instruction
Year 4 Evaluation Survey part I Att 1_IC 7_Survey Year 4 Part I_27 APR 2012.docx	Form and Instruction
Year 4 Evaluation Survey part II Att 2_IC 7_Survey Year 4 Part II_27 APR 2012.docx	Form and Instruction
IC 7_SS Part A_05 16 2012.docx Supporting Statement A	IC Document
IC 7_SS Part B_05 16 2012.docx Supporting Statement B	IC Document
Att 4_IC 7_Introductory Email_27 APR 2012.doc Intro email	IC Document
Att 5_IC 7_Invitation Email_27 APR 2012.doc Invitation email	IC Document
Att 6_IC 7_Followup Email_27 APR 2012.doc Follow-up email	IC Document
Att 7_IC 7_Thank you Email_20 APR 2012.doc Thank you email	IC Document
Att 3_IC 7_Year 4 Survey Screenshots.pdf Survey screenshots	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Year 4 Evaluation Survey part I	Att 1_IC 7_Survey Year 4 Part I_27 APR 2012.docx		Yes	Yes	Fillable Fileable
Form and Instruction	none	Year 4 Evaluation Survey part II	Att 2_IC 7_Survey Year 4 Part II_27 APR 2012.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

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	21	0	0	0	0	0
Annual IC Time Burden (Hours)	21	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
Supporting Statement A	IC 7_SS Part A_05 16 2012.docx	06/11/2012
Supporting Statement B	IC 7_SS Part B_05 16 2012.docx	06/11/2012
Intro email	Att 4_IC 7_Introductory Email_27 APR 2012.doc	06/11/2012
Invitation email	Att 5_IC 7_Invitation Email_27 APR 2012.doc	06/11/2012
Follow-up email	Att 6_IC 7_Followup Email_27 APR 2012.doc	06/11/2012
Thank you email	Att 7_IC 7_Thank you Email_20 APR 2012.doc	06/11/2012
Survey screenshots	Att 3_IC 7_Year 4 Survey Screenshots.pdf	06/11/2012

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