Information Collection

Component 3: Special Projects

IC 248659 under ICR 202208-0920-006 · OMB 0920-1353.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1353 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-21EE Component 3: Special Projects	Form
0920-21EE 3c_Component 3 Comp 3_APR_Form_Year2_12-08-2021_Aug2022_clean.docx	Form
0920-21EE 3c_Component 3 Comp 3_APR_Form_Year2_12-08-2021_Aug2022_clean.docx	Form
Att 4c_Comp 3 instructions_11-5-2021.docx Att 4c_Comp 3 instructions_11-5-2021	IC Document
Att 4c_Comp 3 instructions_11-5-2021.docx Att 4c_Comp 3 instructions_11-5-2021	IC Document

IC Title:

Component 3: Special Projects

Agency IC Tracking Number:

0920-22AV

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Mandatory

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	0920-21EE	3c_Component 3	Comp 3_APR_Form_Year2_12-08-2021_Aug2022_clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14

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
	Approved	Previously Approved
Annual Number of Responses for this IC	14	14
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 4c_Comp 3 instructions_11-5-2021	Att 4c_Comp 3 instructions_11-5-2021.docx	11/18/2021

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