Information Collection

Region XII MSHS T/TA Network Technical Assistance Services Delivery Feedback

IC 233090 under ICR 201801-0970-013 · OMB 0970-0401.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0401 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Region XII MSHS T/TA Network Technical Assistance Services Delivery Feedback	Form and Instruction
1 Region-XII-TTA Feedback Form Region-XII-TTA-Feedback Form.pdf	Form and Instruction
Fast-Track-Submission-Form-OHS-Region-XII-TTA-Feedback.docx Justification	IC Document

IC Title:

Region XII MSHS T/TA Network Technical Assistance Services Delivery Feedback

Agency IC Tracking Number:

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	1	Region-XII-TTA Feedback Form	Region-XII-TTA-Feedback Form.pdf		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification	Fast-Track-Submission-Form-OHS-Region-XII-TTA-Feedback.docx	09/20/2018

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