Innovation Site Visit Discussion Guide - Providers

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⚠️ Notice: This information collection may be referencing outdated material.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
Attachment D5 Innovation recipient protocol.docx Other-Discussion Guide

Information Collection (IC) Details

IC Title:	Innovation Site Visit Discussion Guide - Providers	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
Other-Discussion Guide			Attachment D5 Innovation recipient protocol.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2	2
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	143	143

Documents for IC

Title	Document	Date Uploaded
No associated records found

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