Lead Administrator--Suggested Interviewees Form

Pre-Evaluation Assessments of Nutrition, Physical Activity and Obesity Programs and Policies

Documents and Forms

Document Name Document Type
Form 4 Lead Administrator--Suggested Interviewees Form Form and Instruction
4 Suggested Interviewees Form Att 5B_Suggested Interviewees Form.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Lead Administrator--Suggested Interviewees Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4	Suggested Interviewees Form	Att 5B_Suggested Interviewees Form.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12	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	12	12
Annual IC Time Burden (Hours)	12	12
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.