Annual Progress Report Tool

DELTA Impact Recipient Monitoring and Assessment Tools

Documents and Forms

Document Name Document Type
Form 0920-1247 Annual Progress Report Tool Form and Instruction
0920-1247 Delta Impact DELTA Impact Att. 3a APR Tool 5.15.2020 Updated.docx Form and Instruction
Crosswalk of APR Changes May 14 new format.docx Crosswalk of Changes IC Document
OMB_Change_Request_DELTA_051520 updated 6_8.docx Chnage Request IC Document

Information Collection (IC) Details

IC Title:	Annual Progress Report Tool	Agency IC Tracking Number:	0920-20OW

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	0920-1247	Delta Impact	DELTA Impact Att. 3a APR Tool 5.15.2020 Updated.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	117	117
Annual IC Cost Burden (Dollars)	3,586	3,586

Documents for IC

Title	Document	Date Uploaded
Crosswalk of Changes	Crosswalk of APR Changes May 14 new format.docx	06/18/2020
Chnage Request	OMB_Change_Request_DELTA_051520 updated 6_8.docx	06/18/2020

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