Information Collection

Community Outcomes Module

IC 220477 under ICR 201603-0930-002 · OMB 0930-0358.

Documents and Forms

Document Name Document Type
Form Community Outcomes Community Outcomes Module Form and Instruction
Community Outcomes Community Outcomes Module Attachment 2-SPF-SIG Community Outcomes - data fields.doc Form and Instruction
Attachment 1 SPF-SIG Community Outcomes_ - NOMS.DOCX Community Outcomes_ - NOMS IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Community Outcomes Module	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Community Outcomes Module	Community Outcomes Module	Attachment 2-SPF-SIG Community Outcomes - data fields.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 34	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	34	34
Annual IC Time Burden (Hours)	136	136
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Community Outcomes_ - NOMS	Attachment 1 SPF-SIG Community Outcomes_ - NOMS.DOCX	03/04/2016

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