Information Collection

Needs Assessment Tool

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

Documents and Forms

Documents and forms in this information collection
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

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
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 %

table that charts list of burden
	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

table that charts IC Documents
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.