Information Collection

Recipient-Led Evaluation Reporting

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Category A Recipient-Led Annual Evaluation Report 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

IC Title:

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:

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	n/a				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 %

table that charts list of burden
	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

table that charts IC Documents
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.

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