Information Collection

T/A Follow-up Form

IC 223873 under ICR 201610-0930-002 · OMB 0930-0368.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Technical Assistan T/A Follow-up Form	Form and Instruction
Technical Assistan Technical Assistance Follow-up Form IECMHC_Attachment D_Technical Assistance Follow-up Form_2-10-16.docx	Form and Instruction

IC Title:

T/A Follow-up Form

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	Technical Assistance Follow-up Form	Technical Assistance Follow-up Form	IECMHC_Attachment D_Technical Assistance Follow-up Form_2-10-16.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

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	180	180
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.