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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.