District Assistance Questionnaire

Promoting Adolescent Health through School-Based HIV Prevention

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1275 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-19AUK District Assistance Questionnaire Form and Instruction
0920-19AUK District Assistance Questionnaire Att5-District Assistance Qnr Items.docx Form and Instruction
Att8c-District Assistance Scrn Shot.docx Screenshots IC Document

Information Collection (IC) Details

IC Title:	District Assistance Questionnaire	Agency IC Tracking Number:	0920-19AUK

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	0920-19AUK	District Assistance Questionnaire	Att5-District Assistance Qnr Items.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	350	350
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Screenshots	Att8c-District Assistance Scrn Shot.docx	08/30/2019

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