Information Collection

Component 1 Reporting Template

IC 244060 under ICR 202009-0920-014 · OMB 0920-1329.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.