Information Collection

Recipient-Led Evaluation Annual Report Template

IC 241434 under ICR 202003-0920-010 · OMB 0920-1311.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1311 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Recipient-Led Evaluation Annual Report Template	Form and Instruction
Recipient Evalation Year 3 Effectiveness Brief Att 6c. Cat B Rec Eval Annual Report Temp Y3.docx	Form and Instruction
Recipient Evaluation Year 4 Sustainability and Action Re Att 6d.Cat B Rec Eval Annual Report Temp Y4.docx	Form and Instruction
Recipient Evaluation Year 5 Health Impact Statement Att 6e.Cat B Rec Eval Annual Report Temp Y5 .docx	Form and Instruction
Att 6a. Cat Rec Eval Annual Report Temp Y1.docx Year 1 Implementation Brief	IC Document
Att 6b.Cat B Rec Eval Annual Report Temp Y2.docx Year 2 Efficiency Improvement Plan and Process Model	IC Document

IC Title:

Recipient-Led Evaluation Annual Report Template

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Recipient Evalation Year 3 Effectiveness Brief	Att 6c. Cat B Rec Eval Annual Report Temp Y3.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Recipient Evaluation Year 4 Sustainability and Action Report Guidance	Att 6d.Cat B Rec Eval Annual Report Temp Y4.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Recipient Evaluation Year 5 Health Impact Statement	Att 6e.Cat B Rec Eval Annual Report Temp Y5 .docx	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)	14,688	14,688

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Year 1 Implementation Brief	Att 6a. Cat Rec Eval Annual Report Temp Y1.docx	05/05/2020
Year 2 Efficiency Improvement Plan and Process Model	Att 6b.Cat B Rec Eval Annual Report Temp Y2.docx	05/05/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.