Information Collection

Att 7_Technical Assistance (TA) Satisfaction Instrument

IC 217676 under ICR 201610-0920-011 · OMB 0920-1099.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1099 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 7 TA_Instrument_wordversion.docx	Other-WORD
Att 8 TA_Instrument_screenshot.docx	Other-SCREENSHOTS
Att 10 TA_Intro_Email.docx Att 10_TA Intro Email	IC Document
Att 12 TA_Reminder_Email.docx Att 12_TA Reminder Email	IC Document

IC Title:

Att 7_Technical Assistance (TA) Satisfaction Instrument

Agency IC Tracking Number:

15NR

Is this a Common Form? No

IC Status: Unchanged

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
Other-WORD			Att 7 TA_Instrument_wordversion.docx		Yes	Yes	Fillable Printable
Other-SCREENSHOTS			Att 8 TA_Instrument_screenshot.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,700

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	Previously Approved
Annual Number of Responses for this IC	7,400	7,400
Annual IC Time Burden (Hours)	1,850	1,850
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 10_TA Intro Email	Att 10 TA_Intro_Email.docx	08/21/2015
Att 12_TA Reminder Email	Att 12 TA_Reminder_Email.docx	08/21/2015

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