Information Collection

Capability Assessment

IC 220579 under ICR 202205-0990-006 · OMB 0990-0302.

Documents and Forms

Document Name Document Type
990-0302 Tool 2_Capabilities Assessment.docx Other-Assessment
990-0302 Tool 2_Capabilities Assessment.docx Other-Assessment

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Capability Assessment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-Assessment			990-0302 Tool 2_Capabilities Assessment.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 748	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	748	-141	889
Annual IC Time Burden (Hours)	374	-71	445
Annual IC Cost Burden (Dollars)	0	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.