TA Feedback Form

Evaluation of the Overdose Data to Action Technical Assistance Hub

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1355 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-21BL TA Feedback Form Form and Instruction
0920-21BL Technical Assistance Feedback Form Att 3. TA Feedback Form.docx Form and Instruction
0920-21BL Technical Assistance Feedback Form Att 3. TA Feedback Form.docx Form and Instruction
Att 5. TA Feedback Form Screenshots.docx TA Feedback Form Screenshots IC Document
Att 5. TA Feedback Form Screenshots.docx TA Feedback Form Screenshots IC Document

Information Collection (IC) Details

IC Title:	TA Feedback Form	Agency IC Tracking Number:	0920-21BL

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-21BL	Technical Assistance Feedback Form	Att 3. TA Feedback Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 671	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,342	1,342
Annual IC Time Burden (Hours)	112	112
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
TA Feedback Form Screenshots	Att 5. TA Feedback Form Screenshots.docx	06/10/2021

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