Information Collection

State Implementation Grant Program Questionnaire

IC 209768 under ICR 201312-0915-003 · OMB 0915-0335.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0335 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 STATE IMPLEMENTATION GRANT PROGRAM QUESTIONNAIRE	Form and Instruction
1 STATE IMPLEMENTATION GRANT PROGRAM QUESTIONNAIRE Attachment H State Implementation Grant Questionnaire.docx	Form and Instruction

IC Title:

STATE IMPLEMENTATION GRANT PROGRAM QUESTIONNAIRE

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	STATE IMPLEMENTATION GRANT PROGRAM QUESTIONNAIRE	Attachment H State Implementation Grant Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	13	13
Annual IC Time Burden (Hours)	10	10
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.