MIECHV TACC Needs Assessment Survey

Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Document Name Document Type
Form 1 MIECHV TACC Needs Assessment Survey Form and Instruction
1 TACC Needs Assessment MIECHV TACC Needs Assessment Survey_12 20 12docx.docx Form and Instruction
Supporting Statement1.08.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	MIECHV TACC Needs Assessment Survey	Agency IC Tracking Number:

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	1	TACC Needs Assessment	MIECHV TACC Needs Assessment Survey_12 20 12docx.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	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 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	56	0	0	0	0	0
Annual IC Time Burden (Hours)	14	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	Supporting Statement1.08.docx	01/10/2013

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