Information Collection

Model Plan

IC 184234 under ICR 201108-0970-010 · OMB 0970-0348.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Model Plan	Form and Instruction
1 Model Plan reach model plan 11.doc	Form and Instruction
REACH model plan attachment 1 guidance2011.doc Attachment	IC Document

IC Title:

Model Plan

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	1	Model Plan	reach model plan 11.doc		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

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	51	51
Annual IC Time Burden (Hours)	3,672	3,672
Annual IC Cost Burden (Dollars)	35,700	35,700

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment	REACH model plan attachment 1 guidance2011.doc	08/22/2011

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