Health Center Organizational Assessment

Performance Monitoring of “Working with Publicly Funded Health Centers to Reduce Teen Pregnancy among Youth from Vulnerable Populations

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1156 can be found here:

Documents and Forms

Document Name Document Type
Health Center Organizational Assessment Form and Instruction
Att 4 Health Center Organizational Assessment 03_01_2017 Att 4 Health Center Organizational Assessment 03_01_2017 clean.docx Form and Instruction
Att 4a Health Center Organizational Assessment Online Ve Att 4a Health Center Organizational Assessment Online Version.docx Form

Information Collection (IC) Details

IC Title:	Health Center Organizational Assessment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	N/A	Att 4 Health Center Organizational Assessment 03_01_2017 clean	Att 4 Health Center Organizational Assessment 03_01_2017 clean.docx		Yes	Yes	Fillable Printable
Form	N/A	Att 4a Health Center Organizational Assessment Online Version	Att 4a Health Center Organizational Assessment Online Version.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 21	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	21	21
Annual IC Time Burden (Hours)	42	42
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.