Information Collection

Basic Long-Term Evaluation

IC 225768 under ICR 202003-0920-018 · OMB 0920-0995.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0995 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0995 Basic Long-Term Evaluation	Form and Instruction
0920-0995 Basic Long Term Evaluation Att 31 Basic Long Term Evaluation wordversion.docx	Form and Instruction
0920-0995 Basic Long Term Evaluation screenshot Att 32 Basic Long Term Evaluation Screenshot.pdf	Form

IC Title:

Basic Long-Term Evaluation

Agency IC Tracking Number:

0920-0995

Is this a Common Form? No

IC Status: Modified

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	0920-0995	Basic Long Term Evaluation	Att 31 Basic Long Term Evaluation wordversion.docx		Yes	Yes	Fillable Printable
Form	0920-0995	Basic Long Term Evaluation screenshot	Att 32 Basic Long Term Evaluation Screenshot.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Records of Health Professionals in Disease Prevention and Control Trainnig Programs

FR Citation: 51 FR 226

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	0	0

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.