Information Collection

Grantee program staff-Tier 1 A/B

IC 199778 under ICR 201502-0990-004 · OMB 0990-0392.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-PM OMB ICR Instrument 3 Reporting Form AB Grantees 8-4.docx	Other-survey
0990-0392 Appendix D Example of Evaluation Grantee Consent 5 1 2012 (2).doc	Other-form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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
Other-survey			0990-PM OMB ICR Instrument 3 Reporting Form AB Grantees 8-4.docx		Yes	Yes	Fillable Printable
Other-form			0990-0392 Appendix D Example of Evaluation Grantee Consent 5 1 2012 (2).doc		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 59

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-59	59
Annual IC Time Burden (Hours)	-1,121	1,121
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.