Information Collection

Need for Assitance Worksheet

IC 180783 under ICR 201307-0915-005 · OMB 0915-0285.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0285 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 9 Need for Assitance Worksheet	Form
9 Need for Assistance Worksheet 13. Form 9 - Need of Assistance Worksheet.doc	Form

IC Title:

Need for Assitance Worksheet

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	9	Need for Assistance Worksheet	13. Form 9 - Need of Assistance Worksheet.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 650

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	650	-250	900
Annual IC Time Burden (Hours)	3,250	550	2,700
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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