Information Collection

EBP Self-Assessment Part 2

IC 208313 under ICR 201701-0930-003 · OMB 0930-0339.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Self-Assessment_Pa Self-Assessment_Part_1_and_2 EBP Self-Assessment Part 2	Form and Instruction
Self-Assessment_Pa Self-Assessment_Part_1_and_2 Attachment 3_EBP_Self-Assessment_Part_1_and_2.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Self-Assessment_Part_1_and_2				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 36

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	108	21	0	87
Annual IC Time Burden (Hours)	27	0	-17	44
Annual IC Cost Burden (Dollars)	0	0	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.

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