Information Collection

Readiness and Implementation assessment

IC 227746 under ICR 201707-0935-004 · OMB 0935-0239.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0239 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Readiness and Implementation assessment	Form and Instruction
3 Readiness assessment Attachment F_Readiness Assessment_Data collection instrument_20170727.docx	Form and Instruction
4 Implementation assessment Attachment H_Implementation assessment_Data collection instrument_20170727.docx	Form and Instruction
Attachment E_Readiness assessment_Cover letter and reminder notice_20170727.docx Attachment E – Readiness assessment_Cover letter and reminder notice	IC Document
Attachment G_Implementation assessment_Cover letter and reminder notice_20170727.docx Attachment G – Implementation assessment_Cover letter and reminder notice	IC Document

IC Title:

Readiness and Implementation 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	Readiness assessment	Attachment F_Readiness Assessment_Data collection instrument_20170727.docx		No		Fillable Fileable
Form and Instruction	4	Implementation assessment	Attachment H_Implementation assessment_Data collection instrument_20170727.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 720

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	720	720
Annual IC Time Burden (Hours)	720	720
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment E â Readiness assessment_Cover letter and reminder notice	Attachment E_Readiness assessment_Cover letter and reminder notice_20170727.docx	07/28/2017
Attachment G â Implementation assessment_Cover letter and reminder notice	Attachment G_Implementation assessment_Cover letter and reminder notice_20170727.docx	07/28/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.