Information Collection

Assessment and Plan

IC 197233 under ICR 201104-0970-001 · OMB 0970-0389.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0389 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Assessment and Plan	Form and Instruction
1 Needs Assessment and Plan Tribal HV Implementation Plan Guidance FOR REVIEW.doc	Form and Instruction

IC Title:

Assessment and Plan

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 1320

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	1	Needs Assessment and Plan	Tribal HV Implementation Plan Guidance FOR REVIEW.doc		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18

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 Agency Discretion
Annual Number of Responses for this IC	18	18
Annual IC Time Burden (Hours)	1,800	1,800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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