Information Collection

Benchmark Tool

IC 226025 under ICR 201703-0930-004 · OMB 0930-0375.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Financial Mapping Benchmark Tool	Form and Instruction
Financial Mapping Financial Mapping Interview Attachment 6 Financial Mapping Interview 10-06-2016.docx	Form and Instruction

IC Title:

Benchmark Tool

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	Financial Mapping Interview	Financial Mapping Interview	Attachment 6 Financial Mapping Interview 10-06-2016.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12

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	12	12
Annual IC Time Burden (Hours)	320	320
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.