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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.