Information Collection

Readiness and Implementation assessment

IC 227746 under ICR 202009-0935-001 · OMB 0935-0239.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Readiness and Implementation assessment	Form and Instruction
3 Readiness assessment Attachment F_Readiness Assessment_Data collection instrument_20170727.docx	Form and Instruction
3 Readiness assessment Attachment F_Readiness Assessment_Data clean.docx	Form and Instruction
4 Implementation assessment Attachment H_Implementation assessment_Data collection instrument_20170727.docx	Form and Instruction
4 Implementation assessment Attachment H_Implementation assessment_Data clean.docx	Form and Instruction
Attachment E_Readiness assessment_Cover letter and reminder notice_20170727.docx Attachment E – Readiness assessment_Cover letter and reminder notice	IC Document
Attachment E_Readiness assessment_Cover letter and reminder notice_20170727.docx Attachment E – Readiness assessment_Cover letter and reminder notice	IC Document
Attachment G_Implementation assessment_Cover letter and reminder notice_20170727.docx Attachment G – Implementation assessment_Cover letter and reminder notice	IC Document
Attachment G_Implementation assessment_Cover letter and reminder notice_20170727.docx Attachment G – Implementation assessment_Cover letter and reminder notice	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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
Form and Instruction	3	Readiness assessment	Attachment F_Readiness Assessment_Data clean.docx		No		Fillable Fileable
Form and Instruction	4	Implementation assessment	Attachment H_Implementation assessment_Data clean.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 684

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	684	-36	720
Annual IC Time Burden (Hours)	684	-36	720
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment E â Readiness assessment_Cover letter and reminder notice	Attachment E_Readiness assessment_Cover letter and reminder notice_20170727.docx	07/28/2017
Attachment G â Implementation assessment_Cover letter and reminder notice	Attachment G_Implementation assessment_Cover letter and reminder notice_20170727.docx	07/28/2017

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