Learn Grants Test Model

DATA Act Section 5 Grants Pilot

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Learn Grants Test Model	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.