Information Collection

Needs Assessment Tool

IC 213162 under ICR 201409-0920-011 · OMB 0920-1044.

Documents and Forms

Document Name Document Type
Att 3 Needs_Assessment_Tool.pdf Other-Screen Shots
Att 4_Introductory e-mail.docx Att 4_Introductory E-mail IC Document
Att 4a_Reminder E-mail #2.docx Att 4a_Reminder E-mail IC Document
Att 5 PO Reminder Script.docx Att 5_ Project Officers' Reminder Script IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Needs Assessment Tool	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-Screen Shots			Att 3 Needs_Assessment_Tool.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 42	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	42	42
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 4_Introductory E-mail	Att 4_Introductory e-mail.docx	09/18/2014
Att 4a_Reminder E-mail	Att 4a_Reminder E-mail #2.docx	09/18/2014
Att 5_ Project Officers' Reminder Script	Att 5 PO Reminder Script.docx	01/22/2015

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