Information Collection

Learn Grants Test Model

IC 221789 under ICR 201603-4040-001 · OMB 4040-0017.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Draft_HHS DAP_LG Example Quiz_05232016.docx	Other-Quiz
Draft_HHS DAP_ LG Survey_05232016.docx	Other-Survey
Draft_HHS DAP_LG Question Bank_05232016.docx	Other-Question Bank
4040-0017_Short Supporting Statement LG_June2016_06012016v2 (002)_OMBComment (3).docx Short Supporting Statement	IC Document
4040-0017_SupportingStatementA LG_May2016_05232016.docx Supporting Statement A	IC Document
DRAFT_HHS DAP LG Webinar_05232016.pptx Webinar	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Quiz	Draft_HHS DAP_LG Example Quiz_05232016.docx	Yes	Yes	Fillable Fileable
Other-Survey	Draft_HHS DAP_ LG Survey_05232016.docx	Yes	Yes	Fillable Fileable
Other-Question Bank	Draft_HHS DAP_LG Question Bank_05232016.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 360

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	360	360
Annual IC Time Burden (Hours)	135	135
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Short Supporting Statement	4040-0017_Short Supporting Statement LG_June2016_06012016v2 (002)_OMBComment (3).docx	06/03/2016
Supporting Statement A	4040-0017_SupportingStatementA LG_May2016_05232016.docx	06/03/2016
Webinar	DRAFT_HHS DAP LG Webinar_05232016.pptx	06/03/2016

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