Information Collection

Att. 3a_Screenshots of Metrics Database

IC 222048 under ICR 202012-0920-011 · OMB 0920-1161.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att3a_Screenshots of Metrics Database.docx	Other-Screenshots
Att3b_Metrics Data Dictionary.docx Att. 3b_ Metrics Data Dictionary	IC Document

IC Title:

Agency IC Tracking Number:

16LL

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-Screenshots			Att3a_Screenshots of Metrics Database.docx		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 44

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	176	176
Annual IC Time Burden (Hours)	3,168	3,168
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att. 3b_ Metrics Data Dictionary	Att3b_Metrics Data Dictionary.docx	02/22/2021

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