Implementation Capacity Rubric

Program Evaluation of CDC’s Core State Injury Prevention Program

Documents and Forms

Document Name Document Type
Form 0920-21GB Implementation Capacity Rubric Form and Instruction
0920-21GB Implementation Capacity Development Rubric Attachment E_CoreSIPP_Implementation and Capacity Rubric_OMB.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Implementation Capacity Rubric	Agency IC Tracking Number:	0920-21GB

Is this a Common Form? No		IC Status: New

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	0920-21GB	Implementation Capacity Development Rubric	Attachment E_CoreSIPP_Implementation and Capacity Rubric_OMB.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 23	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	23	23
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	0	0

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.