Information Collection

Recipient-Led Evaluation Reporting

IC 241400 under ICR 201910-0920-009 · OMB 0920-1312.

Documents and Forms

Document Name Document Type
Recipient-Led Evaluation Reporting Form and Instruction
Category A Recipient-Led Annual Evaluation Report Att 5b. 1815 Cat A Eval Report Tool_30Day.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Recipient-Led Evaluation Reporting	Agency IC Tracking Number:

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	n/a	Category A Recipient-Led Annual Evaluation Report	Att 5b. 1815 Cat A Eval Report Tool_30Day.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	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	51	51
Annual IC Time Burden (Hours)	408	408
Annual IC Cost Burden (Dollars)	17,952	17,952

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.