Information Collection

Evaluation data for private-sector organizations

IC 199192 under ICR 201203-0920-003 · OMB 0920-0909.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0909 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Evaluation data for private-sector organizations	Form and Instruction
Att 5a - Evaluation data elements Attachment 5A - Evaluation Data Elements (07.29.11).docx	Form and Instruction
Attachment 5B - Evaluation Data Reminder (07.29.11).docx Att 5b - Evaluation reminder	IC Document
Attachment 5C - Ongoing Evaluation Data Reminder_11 22 2011.docx Attachment 5C - Ongoing Evaluation Data Reminder_11 22 2011	IC Document

IC Title:

Evaluation data for private-sector organizations

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	none	Att 5a - Evaluation data elements	Attachment 5A - Evaluation Data Elements (07.29.11).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 216

Number of Respondents for Small Entity: 36

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	432	432
Annual IC Time Burden (Hours)	432	432
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 5b - Evaluation reminder	Attachment 5B - Evaluation Data Reminder (07.29.11).docx	09/01/2011
Attachment 5C - Ongoing Evaluation Data Reminder_11 22 2011	Attachment 5C - Ongoing Evaluation Data Reminder_11 22 2011.docx	11/28/2011

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