Component 1 Reporting Template

Promoting Adolescent Health through School-Based HIV/STD Prevention Reporting Template

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1329 can be found here:

Documents and Forms

Document Name Document Type
Att 3_Component 1 Reporting Template (1-31-20).docx Other-WORD
Att 3_Component 1 Reporting Template (1-31-20).docx Other-WORD
Att 4_Component 2 Reporting Template 3-6-20.docx Other-WORD
Att 4_Component 2 Reporting Template 3-6-20.docx Other-WORD
3B Reporting Template (3-6-20).docx 3B Reporting Template IC Document
3B Reporting Template (3-6-20).docx 3B Reporting Template IC Document
3C Reporting Template (3-6-20).docx 3C Reporting Template IC Document
3C Reporting Template (3-6-20).docx 3C Reporting Template IC Document

Information Collection (IC) Details

IC Title:	Component 1 Reporting Template	Agency IC Tracking Number:	0920-20KN

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			Att 3_Component 1 Reporting Template (1-31-20).docx		Yes	Yes	Fillable Fileable
Other-WORD			Att 4_Component 2 Reporting Template 3-6-20.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	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
Annual Number of Responses for this IC	240	240
Annual IC Time Burden (Hours)	1,920	1,920
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
3B Reporting Template	3B Reporting Template (3-6-20).docx	10/14/2020
3C Reporting Template	3C Reporting Template (3-6-20).docx	10/14/2020

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