Information Collection

Annual Performance Measures template for the National and State Tobacco Control Program

IC 238890 under ICR 201912-0920-010 · OMB 0920-1097.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1097 Annual Performance Measures template for the National and State Tobacco Control Program	Form and Instruction
0920-1097 Performance Meas Template 1097 Att 4c NTCP Performance Meas Template Final.xlsx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-1097

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	0920-1097	Performance Meas Template	1097 Att 4c NTCP Performance Meas Template Final.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 53

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	53	53
Annual IC Time Burden (Hours)	265	265
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.