Information Collection

TA Feedback Form

IC 247857 under ICR 202106-0920-004 · OMB 0920-1355.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.