Information Collection

State and Community Awardee Performance Measure Reporting Tool

IC 213097 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 Performance Measure Reportin Att 6 (rev2) State and Community Awardee Performance Measure Reporting Tool.docx	Form
0920-0952 Change Request 14AUG2014_REV 10SEPT2014.docx Justification for Change Request	IC Document

IC Title:

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	None	State and Community Awardee Performance Measure Reporting Tool	Att 6 (rev2) State and Community Awardee Performance Measure Reporting Tool.docx	None	No		Paper Only

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	163	163
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification for Change Request	0920-0952 Change Request 14AUG2014_REV 10SEPT2014.docx	09/12/2014

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