Information Collection

DSMES Partner Site-Level Rapid Evaluation Nomination

IC 241401 under ICR 201910-0920-009 · OMB 0920-1312.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
DSMES Partner Site-Level Rapid Evaluation Nomination	Form and Instruction
Att 4a. DSMES Site Nom Form.docx	Other-WORD view of screen shot conte
DSMES Site-Level Rapid Evaluation - Site Nomination Form Att 4aa. DSMES Nom Form Screenshots.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	DSMES Site-Level Rapid Evaluation - Site Nomination Form (screen shots)	Att 4aa. DSMES Nom Form Screenshots.pdf		Yes	Yes	Fillable Fileable
Other-WORD view of screen shot content			Att 4a. DSMES Site Nom Form.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 17

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	17	17
Annual IC Time Burden (Hours)	9	9
Annual IC Cost Burden (Dollars)	374	374

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.