Information Collection

State and Community Awardee Performance Measure Reporting Tool

IC 203973 under ICR 201304-0920-002 · OMB 0920-0952.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0952 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
State and Community Awardee Performance Measure Reporting Tool	Form and Instruction
Att 6 State and Community Awardee Performance Measure Re Att 6 State and Community Awardee Performance Measure Reporting Tool.Revised.docx	Form and Instruction
Att 11. Description of Assessment Tools.docx Att 11	IC Document

IC Title:

State and Community Awardee Performance Measure Reporting Tool

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 and Instruction	N/A	Att 6 State and Community Awardee Performance Measure Reporting Tool.Revised	Att 6 State and Community Awardee Performance Measure Reporting Tool.Revised.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

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

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)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 11	Att 11. Description of Assessment Tools.docx	09/04/2012

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