BIC Capacity Indicators Questionnaire

Evaluation of Core Violence and Injury Prevention Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0916 can be found here:

Documents and Forms

Document Name Document Type
BIC Capacity Indicators Questionnaire Form
SOTS Mock screenshots Attachment G - SOTS Supplement Screenshots.pdf Form
Attachment F-SOTS Supplement.docx SOTs Supplement Word File IC Document

Information Collection (IC) Details

IC Title:	BIC Capacity Indicators Questionnaire	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	none	SOTS Mock screenshots	Attachment G - SOTS Supplement Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 28	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	28	28
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SOTs Supplement Word File	Attachment F-SOTS Supplement.docx	02/08/2013

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