Information Collection

Assessment Form

IC 205169 under ICR 201212-0930-002 · OMB 0930-0336.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0336 can be found here:

Documents and Forms

Document Name Document Type
Form Site Visits Year O Assessment Form Form and Instruction
Site Visits Year O Site Visits Year One Site Visit Form Attachment A-Site Visits Year One Site Visit Interview Guide 12 4 12 Final.docx Form and Instruction
Public Burden Statement.doc Public Burden Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Assessment 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	Site Visits Year One Site Visit Form	Site Visits Year One Site Visit Form	Attachment A-Site Visits Year One Site Visit Interview Guide 12 4 12 Final.docx		No	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 55	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	55	55
Annual IC Time Burden (Hours)	18	18
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Public Burden Statement	Public Burden Statement.doc	12/19/2012

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