Basic Awardees Initial Evaluation Plan

Monitoring and Reporting System for the State Public Health Actions Cooperative Agreements

Documents and Forms

Document Name Document Type
Basic Awardees Initial Evaluation Plan Form
Basic Evaluation Plan Att 4c. Evaluation Work Plan (Basic).docm Form

Information Collection (IC) Details

IC Title:	Basic Awardees Initial Evaluation Plan	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Basic Evaluation Plan	Att 4c. Evaluation Work Plan (Basic).docm		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6	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	6	6
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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