Information Collection

Project Evaluators - State/Tribal

IC 178432 under ICR 201512-0930-006 · OMB 0930-0286.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0286 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form PSI StateTribal Project Evaluators - State/Tribal	Form and Instruction
PSI StateTribal PSI StateTribal Att C.1 PSI StateTribal Dec2015.docx	Form and Instruction
TASP StateTribal TASP StateTribal Att D.1 TASP StateTribal Dec2015.docx	Form and Instruction
EIRF-Individual Fo EIRF-Individual Form StateTribal Att G. EIRF-Individual Form (StateTribal) Dec2015.docx	Form and Instruction
EIRF-Screening For EIRF-Screening Form StateTribal Att H. EIRF-Screening Form (StateTribal) Dec2015.docx	Form and Instruction

IC Title:

Project Evaluators - State/Tribal

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	PSI StateTribal	PSI StateTribal	Att C.1 PSI StateTribal Dec2015.docx	Yes	Yes	Fillable Fileable
Form and Instruction	TASP StateTribal	TASP StateTribal	Att D.1 TASP StateTribal Dec2015.docx	Yes	Yes	Fillable Fileable
Form and Instruction	EIRF-Individual Form StateTribal	EIRF-Individual Form StateTribal	Att G. EIRF-Individual Form (StateTribal) Dec2015.docx	Yes	Yes	Fillable Fileable
Form and Instruction	EIRF-Screening Form StateTribal	EIRF-Screening Form StateTribal	Att H. EIRF-Screening Form (StateTribal) Dec2015.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 43

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	Previously Approved
Annual Number of Responses for this IC	688	-185	873
Annual IC Time Burden (Hours)	430	-1,173	1,603
Annual IC Cost Burden (Dollars)	0	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.