Information Collection

EBP Self-Assessment Part 1

IC 208312 under ICR 201308-0930-002 · OMB 0930-0339.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0339 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form EBP Self-Assessmen EBP Self-Assessment Part 1	Form and Instruction
EBP Self-Assessmen EBP Self-Assessment Part 1 and Part 2 Attachment 03_EBP Self-Assessment Part 1 and Part 2.docx	Form and Instruction
Attachment 08_EBP Web Consent.docx EBP Web Consent	IC Document

IC Title:

EBP Self-Assessment Part 1

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	EBP Self-Assessment Part 1 and Part 2	EBP Self-Assessment Part 1 and Part 2	Attachment 03_EBP Self-Assessment Part 1 and Part 2.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 127

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	127	127
Annual IC Time Burden (Hours)	74	74
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
EBP Web Consent	Attachment 08_EBP Web Consent.docx	08/19/2013

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