Information Collection

PHC Tailoring Questions

IC 227355 under ICR 201706-0920-012 · OMB 0920-1211.

Documents and Forms

Document Name Document Type
PHC Tailoring Questions Form and Instruction
PHC Tailoring Questions - Att 7 Att 7 PHC tailoring questions05.11.17.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	PHC Tailoring Questions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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	NA	PHC Tailoring Questions - Att 7	Att 7 PHC tailoring questions05.11.17.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 168	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	504	504
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.