Information Collection

District Assistance Questionnaire

IC 237606 under ICR 201908-0920-010 · OMB 0920-1275.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.