Quarterly Health Center Performance Measure Reporting Tool

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 Quarterly Health Center Performance Measure Reporting Tool Form and Instruction
0920-1156 Quarterly Health Center Performance Measure Reporting To Att 5a Quarterly Health Center Performance Measure Reporting Tool final.docx Form and Instruction
0920-1156 Quarterly Health Center Performance Measure Reporting To Att 5b Quarterly Health Center Performance Measure Reporting Tool Online Version.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Quarterly Health Center Performance Measure Reporting Tool	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	Quarterly Health Center Performance Measure Reporting Tool	Att 5a Quarterly Health Center Performance Measure Reporting Tool final.docx		Yes	Yes	Fillable Printable
Form and Instruction	0920-1156	Quarterly Health Center Performance Measure Reporting Tool Online	Att 5b Quarterly Health Center Performance Measure Reporting Tool 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: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	42	-21	63
Annual IC Time Burden (Hours)	168	-84	252
Annual IC Cost Burden (Dollars)	0	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.