Information Collection

Site Assessment Form for Street/Outreach Workers

IC 255802 under ICR 202209-0920-006 · OMB 0920-1372.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1372 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Site Assessment Form for Street/Outreach Workers	Form and Instruction
Site Assessment Form - Street/Outreach Workers Att_7_Site_Assessment_Outreach.docx	Form and Instruction
Site Assessment Form - Street/Outreach Workers Att_7_Site_Assessment_Outreach.docx	Form and Instruction

IC Title:

Site Assessment Form for Street/Outreach Workers

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
Form and Instruction	NA	Site Assessment Form - Street/Outreach Workers	Att_7_Site_Assessment_Outreach.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	10	10
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.