State Offices of Rural Health TA Data Collection Form

State Office of Rural Health Grant Technical Assistance

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0322 can be found here:

Documents and Forms

Document Name Document Type
Form 1 State Offices of Rural Health TA Data Collection Form Form and Instruction
SORH PIMS EXAMPLE FY 14.pdf Other-sample
Copy of FY TA and Client by State Trending Report FY 08-14 (002).xlsx Other-Trending Report
1 TA Request Form SORH TA PIMS Screenshot.doc Form and Instruction

Information Collection (IC) Details

IC Title:	State Offices of Rural Health TA Data Collection Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	TA Request Form	SORH TA PIMS Screenshot.doc	Yes	Yes	Fillable Fileable
Other-sample			SORH PIMS EXAMPLE FY 14.pdf	Yes	Yes	Fillable Fileable
Other-Trending Report			Copy of FY TA and Client by State Trending Report FY 08-14 (002).xlsx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	625	625
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.