Information Collection

Evaluation Form - Administrators

IC 199793 under ICR 201206-0920-003 · OMB 0920-0914.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0914 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Evaluation Form - Administrators	Form
Evaluation Form 10 7 2011attachment-C1.docx	Form
Appendix D updated 9.30.11.docx Letter of Introduction and Fact Sheet	IC Document

IC Title:

Evaluation Form - Administrators

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	none	Evaluation Form	10 7 2011attachment-C1.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter of Introduction and Fact Sheet	Appendix D updated 9.30.11.docx	10/13/2011

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