Information Collection

Community Outcomes Module

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
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 %

table that charts list of burden
	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

table that charts IC Documents
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.