Information Collection

Mid-Course technical Assistance Feedback Form

IC 202151 under ICR 201103-0930-003 · OMB 0930-0197.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0197 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Mid-Course Feedbac Mid-Course technical Assistance Feedback Form	Form and Instruction
Mid-Course Feedbac Mid-Course Feedback Form Attachment 1 Mid Course Feedback Form.docx	Form and Instruction
Technical Assistance Enterprise, Mid-Course Feedback Form, 5.4.12.doc Justification	IC Document
Trans.Let-2-2012.doc Transmit Letter	IC Document

IC Title:

Mid-Course technical Assistance Feedback Form

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	Mid-Course Feedback Form	Mid-Course Feedback Form	Attachment 1 Mid Course Feedback Form.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

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	100	0	0	0	0	0
Annual IC Time Burden (Hours)	20	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
Justification	Technical Assistance Enterprise, Mid-Course Feedback Form, 5.4.12.doc	05/04/2012
Transmit Letter	Trans.Let-2-2012.doc	05/04/2012

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