Evaluation and Performance Measuring Plan Template – Initial Population

Monitoring and Reporting for the Overdose Data to Action Cooperative Agreement

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1283 can be found here:

Documents and Forms

Document Name Document Type
Evaluation and Performance Measuring Plan Template – Initial Population Form and Instruction
Evaluation and Performance Measuring Plan Template Att 3a Evaluation and Performance Plan.DOC Form and Instruction
Evaluation and Performance Measuring Plan Template Att 3a Evaluation and Performance Plan.DOC Form and Instruction

Information Collection (IC) Details

IC Title:	Evaluation and Performance Measuring Plan Template – Initial Population	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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	n/a	Evaluation and Performance Measuring Plan Template	Att 3a Evaluation and Performance Plan.DOC		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 22	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	22	22
Annual IC Time Burden (Hours)	264	264
Annual IC Cost Burden (Dollars)	8,800	8,800

Documents for IC

Title	Document	Date Uploaded
No associated records found

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