Information Collection

DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators

IC 207599 under ICR 201112-0920-014 · OMB 0920-0919.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0919 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators	Form
Annual Grantee Meeting Survey Att 1_AnnualMtgIdeaGenSurv.docx	Form
Interim Progress Report Att 2_ElectronicIPR.docx	Form
Monthly Conference Call Evaluation Att 3_MonthlyConfCallEval.docx	Form
Workplan Feedback Survey Att 4_ElectronicWorkplan.docx	Form
Resource Center Evaluation Att 5_RETTConferenceCallScreenshots.docx	Form
State Evaluation Think Tank Att 6_SETTGrpCall.docx	Form
State Evaluation Think Tank Group Feedback Att 7_SETTGrpFeedback.docx	Form
Resource Center Eval Think Tank Att 8_RETTGroupFeedbackScreenshots.docx	Form
Post Evaluation Webinar Att 9_PostEvalWebinarSurvey.docx	Form
Disability and Health Interventions Att 10_DisabilityInterventions.docx	Form
Disability and Health Branch Site Visit Att 11_SiteVisitEval.docx	Form
OMBDraft_SubmissionTem_(rev06272013).docx Request for Approval	IC Document

IC Title:

DHDD Continuous Quality Improvement Surveys for State and National PHPRC Disability and Health Coordinators

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Annual Grantee Meeting Survey	Att 1_AnnualMtgIdeaGenSurv.docx	Yes	Yes	Fillable Fileable
Form	none	Interim Progress Report	Att 2_ElectronicIPR.docx	Yes	Yes	Fillable Fileable
Form	none	Monthly Conference Call Evaluation	Att 3_MonthlyConfCallEval.docx	Yes	Yes	Fillable Fileable
Form	none	Workplan Feedback Survey	Att 4_ElectronicWorkplan.docx	Yes	Yes	Fillable Fileable
Form	none	Resource Center Evaluation	Att 5_RETTConferenceCallScreenshots.docx	Yes	Yes	Fillable Fileable
Form	none	State Evaluation Think Tank	Att 6_SETTGrpCall.docx	Yes	Yes	Fillable Fileable
Form	none	State Evaluation Think Tank Group Feedback	Att 7_SETTGrpFeedback.docx	Yes	Yes	Fillable Fileable
Form	none	Resource Center Eval Think Tank	Att 8_RETTGroupFeedbackScreenshots.docx	Yes	Yes	Fillable Fileable
Form	none	Post Evaluation Webinar	Att 9_PostEvalWebinarSurvey.docx	Yes	Yes	Fillable Fileable
Form	none	Disability and Health Interventions	Att 10_DisabilityInterventions.docx	Yes	Yes	Fillable Fileable
Form	none	Disability and Health Branch Site Visit	Att 11_SiteVisitEval.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 404

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	404	0	0	0	0	0
Annual IC Time Burden (Hours)	85	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
Request for Approval	OMBDraft_SubmissionTem_(rev06272013).docx	06/27/2013

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