Att 6_ Instrument: PREVENTION INFRASTRUCTURE ASSESSMENT

Delta Impact Cooperative Agreement Evaluation data collection Instruments

Documents and Forms

Document Name Document Type
Form 0920- Att 6_ Instrument: PREVENTION INFRASTRUCTURE ASSESSMENT Form and Instruction
0920- Instrument: Key Informant Interview – Lead Evaluator DELTA Impact Att 6 - Prevention Infrastructure Assessment Survey Updated.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Att 6_ Instrument: PREVENTION INFRASTRUCTURE ASSESSMENT	Agency IC Tracking Number:	0920-20JC

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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-	Instrument: Key Informant Interview – Lead Evaluator	DELTA Impact Att 6 - Prevention Infrastructure Assessment Survey 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 %

	Requested	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	20	10	10
Annual IC Time Burden (Hours)	20	0	20
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.