Information Collection

Technical Assistance (TA) Satisfaction Instrument

IC 217676 under ICR 201902-0920-009 · OMB 0920-1099.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
TA Satisfaction Follow-up Technical Assistance (TA) Satisfaction Instrument	Form
TA Follow-up -screenshots Technical Assistance (TA) Satisfaction Instrument	Form
TA Satisfaction Follow-up Att 7_TA Satisfaction Follow-up Instrument.docx	Form
TA Follow-up -screenshots Att 8_TA Satisfaction_screenshot.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	none				Yes	Yes	Fillable Fileable
Form	none				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,700

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	Previously Approved
Annual Number of Responses for this IC	7,400	7,400
Annual IC Time Burden (Hours)	1,850	1,850
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.

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