Information Collection

Evaluation Form for Sites

IC 218087 under ICR 201906-0920-014 · OMB 0920-1090.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1090 Evaluation Form for Sites	Form
0920-1090 Evaluation Form for Sites 0920 1090 Att 3B 1705 Evaluation Form for Sites Final.xlsx	Form
0920 1090 Att 3C Glossary of Terms Final.docx Glossary of Terms	IC Document

IC Title:

Agency IC Tracking Number:

0920-1090

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	0920-1090	Evaluation Form for Sites	0920 1090 Att 3B 1705 Evaluation Form for Sites Final.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 5

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Glossary of Terms	0920 1090 Att 3C Glossary of Terms Final.docx	07/02/2019

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