Awardee Administrators Program Survey

WISEWOMAN National Program Evaluation: Implementation Assessment

Documents and Forms

Document Name Document Type
Awardee Administrators Program Survey Form
Awardee Administrators Program Survey Attachment C1 WISEWOMAN program survey.docx Form
Attachment C2 Program survey invitation.docx Survey Invitation IC Document
Attachment C3 Program survey reminder.docx Survey Reminder IC Document

Information Collection (IC) Details

IC Title:	Awardee Administrators Program Survey	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
Form	none	Awardee Administrators Program Survey	Attachment C1 WISEWOMAN program survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	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	15	15
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Survey Invitation	Attachment C2 Program survey invitation.docx	12/04/2014
Survey Reminder	Attachment C3 Program survey reminder.docx	12/04/2014

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