Health Center Organizational Assessment

Performance Monitoring of “Working with Publicly Funded Health Centers to Reduce Teen Pregnancy among Youth from Vulnerable Populations

Documents and Forms

Document Name Document Type
Form 0920-1156 Health Center Organizational Assessment Form and Instruction
0920-1156 Health Center Org Assessment Att 3a Health Center Organizational Assessment 6_22_2016 final.docx Form and Instruction
0920-1156 Health Center Org Assessment Online Att 3b Health Center Organizational Assessment Online Version.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Health Center Organizational Assessment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	0920-1156	Health Center Org Assessment	Att 3a Health Center Organizational Assessment 6_22_2016 final.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1156	Health Center Org Assessment Online	Att 3b Health Center Organizational Assessment Online Version.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 21	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Previously Approved
Annual Number of Responses for this IC	21	21
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

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.