Information Collection

Community-Based Organizations - Agency Data

IC 180693 under ICR 201508-0920-003 · OMB 0920-0696.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0696 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attach5 PEB NHME Comprehensive DVS v11-02-2012.pdf	Other-EvaluationWeb
Attach3B EW home page user.png	Other-EvaluationWeb

IC Title:

Community-Based Organizations - Agency Data

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

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-EvaluationWeb			Attach5 PEB NHME Comprehensive DVS v11-02-2012.pdf		Yes	Yes	Fillable Printable
Other-EvaluationWeb			Attach3B EW home page user.png		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-400	400
Annual IC Time Burden (Hours)	-200	200
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.