Information Collection

TB DST Reference Center for MTBC Assessment – Online Survey

IC 224646 under ICR 201407-0920-003 · OMB 0920-1027.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1027 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
TB DST Reference Center for MTBC Assessment – Online Survey	Form and Instruction
National PHL DST Reference Center for MTBC Survey Appendix 2- Web shots TB DST Survey.docx	Form and Instruction
Appendix 1-TB DST Survey Questions.docx NPHL DST Reference Center for MTBC Survey - WORD	IC Document
TB DST Reference Center Project Determination_CW_ JD.pdf Research Determination	IC Document
TB OnlineSurvey Service DeliveryChecklist.docx GenIC 0920-1027 Checklist	IC Document
Template-TB DST Survey_Online 30NOV2016.docx 0920-1027 GenIC Request	IC Document

IC Title:

TB DST Reference Center for MTBC Assessment â Online Survey

Agency IC Tracking Number:

0920-1027-17FL

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	NA	National PHL DST Reference Center for MTBC Survey	Appendix 2- Web shots TB DST Survey.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24

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	24	24
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
NPHL DST Reference Center for MTBC Survey - WORD	Appendix 1-TB DST Survey Questions.docx	11/30/2016
Research Determination	TB DST Reference Center Project Determination_CW_ JD.pdf	11/30/2016
GenIC 0920-1027 Checklist	TB OnlineSurvey Service DeliveryChecklist.docx	11/30/2016
0920-1027 GenIC Request	Template-TB DST Survey_Online 30NOV2016.docx	11/30/2016

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