Information Collection

Evaluation and Performance Measuring Plan Template - Annual Reporting

IC 238169 under ICR 202108-0920-016 · OMB 0920-1283.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Evaluation and Performance Measuring Plan Template - Annual Reporting	Form and Instruction
Evaluation and Performance Measuring Plan Template Overdose Data to Action Evaluation Plan Template_Clean 08112021.docx	Form and Instruction
Evaluation and Performance Measuring Plan Template Overdose Data to Action Evaluation Plan Template_Clean 08112021.docx	Form and Instruction

IC Title:

Evaluation and Performance Measuring Plan Template - Annual Reporting

Agency IC Tracking Number:

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
Form and Instruction	n/a	Evaluation and Performance Measuring Plan Template	Overdose Data to Action Evaluation Plan Template_Clean 08112021.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 66

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
	Requested	Previously Approved
Annual Number of Responses for this IC	66	66
Annual IC Time Burden (Hours)	264	264
Annual IC Cost Burden (Dollars)	8,802	8,802

Documents for IC

table that charts IC Documents
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.