Information Collection

Title X Outreach and Enrollment Report

IC 211642 under ICR 201405-0990-004 · OMB 0990-0423.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0423 can be found here:

Documents and Forms

Document Name Document Type
0990-New_Title X outreach and enrollment sample data collection form.docx Other-Report

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Title X Outreach and Enrollment Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Report			0990-New_Title X outreach and enrollment sample data collection form.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,200	4,200
Annual IC Time Burden (Hours)	840	840
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.