Information Collection

Assessment

IC 226274 under ICR 201702-0920-009 · OMB 0920-1209.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1209 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Assessment	Form
Assessment Att 4c_Assessment_02-15-2017.docx	Form
Example Assessment Screenshots for HIV- Participants Att 4d_M-Cubed P2 Assessment (HIV-) Screenshots (rev 2-15-17).pdf	Form
Example Assessment Screenshots for HIV+ Participants Att 4e_M-Cubed P2 Assessment (HIV+) Screenshots (rev 2-15-17).pdf	Form

IC Title:

Assessment

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	N/A	Assessment	Att 4c_Assessment_02-15-2017.docx	Yes	Yes	Fillable Fileable
Form	N/A	Example Assessment Screenshots for HIV- Participants	Att 4d_M-Cubed P2 Assessment (HIV-) Screenshots (rev 2-15-17).pdf	Yes	Yes	Fillable Fileable
Form	N/A	Example Assessment Screenshots for HIV+ Participants	Att 4e_M-Cubed P2 Assessment (HIV+) Screenshots (rev 2-15-17).pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 603

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	2,412	2,412
Annual IC Time Burden (Hours)	3,618	3,618
Annual IC Cost Burden (Dollars)	84,046	84,046

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.