Information Collection

Interview Planning Tool

IC 195050 under ICR 201010-0920-010 · OMB 0920-0876.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Interview Planning Tool	Form
Interview Planning Tool Attachment 7a Interview Planning Tool.doc	Form
Attachment 7c Case Study FAQs for CPPW-Affordable Care Act Sites.doc Att 7c - FAQ	IC Document
Attachment 7b CPPW Case Study Introductory Letter.doc Att 7b - Introductory Letter	IC Document
Attachment 7d Introductory e-mail to schedule site visit preparatory call.doc Att 7d - Introductory Email	IC Document
Attachment 7e Site Visit Preparatory Call.doc Att 7e - Script for Preparatory Call	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	none	Interview Planning Tool	Attachment 7a Interview Planning Tool.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24

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	24	24
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 7c - FAQ	Attachment 7c Case Study FAQs for CPPW-Affordable Care Act Sites.doc	10/22/2010
Att 7b - Introductory Letter	Attachment 7b CPPW Case Study Introductory Letter.doc	10/22/2010
Att 7d - Introductory Email	Attachment 7d Introductory e-mail to schedule site visit preparatory call.doc	10/22/2010
Att 7e - Script for Preparatory Call	Attachment 7e Site Visit Preparatory Call.doc	10/22/2010

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