Information Collection

Evaluation Plan

IC 227233 under ICR 202005-0930-001 · OMB 0930-0377.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0377 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Evaluation Plan Evaluation Plan	Form and Instruction
Evaluation Plan Evaluation Plan Attachment_6_SPF-Rx_EvalChecklist_6_19_17_.pdf	Form and Instruction

IC Title:

Evaluation Plan

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	Evaluation Plan	Evaluation Plan	Attachment_6_SPF-Rx_EvalChecklist_6_19_17_.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25

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
	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-25	25
Annual IC Time Burden (Hours)	-200	200
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.