Information Collection

Attachment 5 -- Evaluation Site Champion Interview

IC 244081 under ICR 202010-0935-001 · OMB 0935-0257.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Attachment 5 -- Evaluation Site Champion Interview	Form and Instruction
5 Attachment 5 -- Evaluation Site Champion Interview Attachment 5_Evaluation Site Champion Interview.docx	Form and Instruction
60 Day FRN.pdf Attachment 6 -- Federal Register Notice	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	5	Attachment 5 -- Evaluation Site Champion Interview	Attachment 5_Evaluation Site Champion Interview.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 6 -- Federal Register Notice	60 Day FRN.pdf	10/14/2020

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