Information Collection

WISEWOMAN Programs

IC 183886 under ICR 201103-0920-002 · OMB 0920-0679.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CHB MIS Data Collection Tool.doc	Other-WORD
Attachment 6. Proposed Revisions.doc	Other-WORD
Attachment 5. Usability Results.doc Usability Testing Results	IC Document
Attachment 4. Usability Test Participants.doc Usability and Pilot Tests Participants	IC Document

IC Title:

WISEWOMAN Programs

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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
Other-WORD			CHB MIS Data Collection Tool.doc		No	No	Fillable Printable
Other-WORD			Attachment 6. Proposed Revisions.doc		No	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

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
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-30	30
Annual IC Time Burden (Hours)	-180	180
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Usability Testing Results	Attachment 5. Usability Results.doc	01/16/2008
Usability and Pilot Tests Participants	Attachment 4. Usability Test Participants.doc	01/16/2008

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