Information Collection

State and Community Awardee Performance Measure Reporting Tool

IC 203973 under ICR 201409-0920-009 · OMB 0920-0952.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
State and Community Awardee Performance Measure Reporting Tool	Form
State and Community Awardee Tool Att 6 (rev) State and Community Awardee Performance Measure Reporting Tool.docx	Form
Att 11. Description of Assessment Tools.docx Att 11	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	none	State and Community Awardee Tool	Att 6 (rev) State and Community Awardee Performance Measure Reporting Tool.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-50	50
Annual IC Time Burden (Hours)	-200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 11	Att 11. Description of Assessment Tools.docx	09/04/2012

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