Information Collection

Region XII MSHS T/TA Network Technical Assistance Services Delivery Feedback

IC 233090 under ICR 202105-0970-001 · OMB 0970-0401.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0401 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Region XII MSHS T/TA Network Technical Assistance Services Delivery Feedback	Form and Instruction
1 Region-XII-TTA Feedback Form Region-XII-TTA-Feedback Form.pdf	Form and Instruction
1 Region-XII-TTA Feedback Form Region-XII-TTA-Feedback Form.pdf	Form and Instruction
Fast-Track-Submission-Form-OHS-Region-XII-TTA-Feedback.docx Justification	IC Document
Fast-Track-Submission-Form-OHS-Region-XII-TTA-Feedback.docx Justification	IC Document

IC Title:

Region XII MSHS T/TA Network Technical Assistance Services Delivery Feedback

Agency IC Tracking Number:

IC Status: Unchanged

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	1	Region-XII-TTA Feedback Form	Region-XII-TTA-Feedback Form.pdf		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification	Fast-Track-Submission-Form-OHS-Region-XII-TTA-Feedback.docx	09/20/2018

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