Information Collection

Grantee Program staff-Tier 1 C/D and Ter 2/PREIS

IC 199779 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 4 Reporting Form CD Grantees 8-4.docx	Other-Performance Measure reporting
0990-0392 Appendix D Example of Evaluation Grantee Consent 5 1 2012 (2).doc 0990-0392 Appendix D Example of Evaluation Grantee Consent 5 1 2012 (2)	IC Document

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-Performance Measure reporting form			0990-PM OMB ICR Instrument 4 Reporting Form CD Grantees 8-4.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 48

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-48	48
Annual IC Time Burden (Hours)	-1,008	1,008
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0990-0392 Appendix D Example of Evaluation Grantee Consent 5 1 2012 (2)	0990-0392 Appendix D Example of Evaluation Grantee Consent 5 1 2012 (2).doc	05/09/2012

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