Information Collection

Awardee Administrators Network Survey

IC 214150 under ICR 201412-0920-005 · OMB 0920-1068.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Awardee Administrators Network Survey	Form
Administrators Network Survey Attachment D1 WISEWOMAN network survey.docx	Form
Attachment D2 network survey invitation.docx Survey Invitation	IC Document
Attachment D3 network survey reminder.docx Survey reminder	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	Administrators Network Survey	Attachment D1 WISEWOMAN network 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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey Invitation	Attachment D2 network survey invitation.docx	12/04/2014
Survey reminder	Attachment D3 network survey reminder.docx	12/04/2014

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