Program Survey

WISEWOMAN National Program Evaluation

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1279 can be found here:

Documents and Forms

Document Name Document Type
Program Survey Form
Program Survey Attachment C1 Program Survey_revised 07 23 2019.docx Form
Attachment C2 Program survey invitation.docx Survey Invitation Email IC Document
Attachment C3 Program survey reminder.docx Survey Reminder Email IC Document

Information Collection (IC) Details

IC Title:	Program Survey	Agency IC Tracking Number:

Is this a Common Form? No		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	none	Program Survey	Attachment C1 Program Survey_revised 07 23 2019.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 16	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	16	16
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	772	772

Documents for IC

Title	Document	Date Uploaded
Survey Invitation Email	Attachment C2 Program survey invitation.docx	10/10/2019
Survey Reminder Email	Attachment C3 Program survey reminder.docx	10/10/2019

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