Information Collection

State & Local HH & LPP Programs: Baseline Profile Assessment

IC 220160 under ICR 201412-0920-011 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0879 State & Local HH & LPP Programs: Baseline Profile Assessment	Form and Instruction
0920-0879 Att C InstrumentMSWord Att C InstrumentMSWord.docx	Form and Instruction
0920-0879 Att D Instrument Web Version Att D Instrument Web Version.docx	Form and Instruction
Att E Notification Email.docx Att E Notification Email	IC Document
Att F Reminder Email.docx Att F Reminder Email	IC Document
Att A Awarded Jurisdictions.docx Att A Awarded Jurisdictions	IC Document
Att B Letter for Bona Fide Agent.pdf Att B Letter for Bona Fide Agent	IC Document
Final PROF-LEAD-SSA.docx Final PROF-LEAD-SSA	IC Document
Final PROF-LEAD-SSB.docx Final PROF-LEAD-SSB	IC Document

IC Title:

State & Local HH & LPP Programs: Baseline Profile Assessment

Agency IC Tracking Number:

16PM

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 and Instruction	0920-0879	Att C InstrumentMSWord	Att C InstrumentMSWord.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0879	Att D Instrument Web Version	Att D Instrument Web Version.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35

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	35	35
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att E Notification Email	Att E Notification Email.docx	02/18/2016
Att F Reminder Email	Att F Reminder Email.docx	02/18/2016
Att A Awarded Jurisdictions	Att A Awarded Jurisdictions.docx	02/18/2016
Att B Letter for Bona Fide Agent	Att B Letter for Bona Fide Agent.pdf	02/18/2016
Final PROF-LEAD-SSA	Final PROF-LEAD-SSA.docx	02/18/2016
Final PROF-LEAD-SSB	Final PROF-LEAD-SSB.docx	02/18/2016

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