Awardee Administrators Network Survey

WISEWOMAN National Program Evaluation: Implementation Assessment

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Awardee Administrators Network 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	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 %

	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

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.