Special Emphasis Panel (SEP) Peer Review Evaluation for Quality Improvement

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1050 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-1050 Special Emphasis Panel (SEP) Peer Review Evaluation for Quality Improvement Form and Instruction
0920-1050 Peer Reviewers Evaluation Form Att 1_Peer Reviewers' Evaluation Form final.docx Form and Instruction
0920-1050 _Service Delivery_SEP Peer Review Evaluation final.docx Template Information IC Document
Att 2_PIA Email.pdf PIA email IC Document

Information Collection (IC) Details

IC Title:	Special Emphasis Panel (SEP) Peer Review Evaluation for Quality Improvement	Agency IC Tracking Number:	0920-1050-20FM

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	0920-1050	Peer Reviewers Evaluation Form	Att 1_Peer Reviewers' Evaluation Form final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	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	500	500
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Template Information	0920-1050 _Service Delivery_SEP Peer Review Evaluation final.docx	01/09/2020
PIA email	Att 2_PIA Email.pdf	01/09/2020

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