Work Plan Instrument

Preventive Health and Health Services Block Grant

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0106 can be found here:

Documents and Forms

Document Name Document Type
Work Plan Instrument Form and Instruction
Work plan instruments Att E_Work Plan Instruments (003)-Updated 081420.docx Form and Instruction
Work plan instruments Att E_Work Plan Instruments (003)-Updated 081420.docx Form and Instruction
Att I WorkPlanGuidance 1-25-19. PDF_Final.pdf Att I_WorkPlanGuidance IC Document
Att I WorkPlanGuidance 1-25-19. PDF_Final.pdf Att I_WorkPlanGuidance IC Document

Information Collection (IC) Details

IC Title:	Work Plan Instrument	Agency IC Tracking Number:

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	none	Work plan instruments	Att E_Work Plan Instruments (003)-Updated 081420.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 61	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	61	0	61
Annual IC Time Burden (Hours)	732	-488	1,220
Annual IC Cost Burden (Dollars)	252,247	252,247	0

Documents for IC

Title	Document	Date Uploaded
Att I_WorkPlanGuidance	Att I WorkPlanGuidance 1-25-19. PDF_Final.pdf	06/27/2019

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