Information Collection

Submission of NQDW Intake Questionnaire Electronic Data File

IC 204102 under ICR 202207-0920-001 · OMB 0920-0856.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0856 can be found here:

Documents and Forms

Document Name Document Type
0856 NQDW Att G2_NQDW SFTP Instructions for States.docx Instruction
0856 NQDW Att G2_NQDW SFTP Instructions for States.docx Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Submission of NQDW Intake Questionnaire Electronic Data File	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
Instruction			0856 NQDW Att G2_NQDW SFTP Instructions for States.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 54	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	216	0	216
Annual IC Time Burden (Hours)	216	0	216
Annual IC Cost Burden (Dollars)	5,841	9	5,832

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.