Information Collection

State and Community Awardee Staff Needs Assessment

IC 203975 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 Staff Needs Assessment	Form
new Web-based Survey Attachment 8 (web) State and Community Awardee Staff Needs Assessment.pdf	Form
Attachment 8 (rev) State and Community Awardee Staff Needs Assessment.docx Survey -Word version	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	new Web-based Survey	Attachment 8 (web) State and Community Awardee Staff Needs Assessment.pdf		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
	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey -Word version	Attachment 8 (rev) State and Community Awardee Staff Needs Assessment.docx	04/02/2013

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