Information Collection

Follow-up Survey -Community Health workers

IC 219185 under ICR 202208-0990-001 · OMB 0990-0407.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-0407Appendix D - TCH Follow-Up Survey (Community Health Workers)(12.2.15).pdf	Other-forms
0990-0407Appendix D - TCH Follow-Up Survey (Community Health Workers)(12.2.15).pdf	Other-forms

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Voluntary

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
Other-forms			0990-0407Appendix D - TCH Follow-Up Survey (Community Health Workers)(12.2.15).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-12	12
Annual IC Time Burden (Hours)	-2	2
Annual IC Cost Burden (Dollars)	0	0

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.