Information Collection

Program Data Collection Tool

IC 208624 under ICR 201309-0915-002 · OMB 0915-0376.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0376 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Program Data Collection Tool	Form and Instruction
1 Program Data Collection Tool Instrument - Program Data Collection Tool.docx	Form and Instruction

IC Title:

Program Data Collection Tool

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	1	Program Data Collection Tool	Instrument - Program Data Collection Tool.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 45

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	45	45
Annual IC Time Burden (Hours)	360	360
Annual IC Cost Burden (Dollars)	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.