Information Collection

District Assistance Questionnaire

IC 237606 under ICR 202209-0920-014 · OMB 0920-1275.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
District Assistance Questionnaire	Form and Instruction
PERS: District Assistance Questionnaire Att5_District Assistance Qnr Items.docx	Form and Instruction
PERS: District Assistance Questionnaire Att5_District Assistance Qnr Items.docx	Form and Instruction
Att8c-District Assistance Scrn Shot.docx Example screenshots (PERS: District Assistance Questionnaire)	IC Document
Att8c-District Assistance Scrn Shot.docx Example screenshots (PERS: District Assistance Questionnaire)	IC Document

IC Title:

Agency IC Tracking Number:

0920-19AUK

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	None	PERS: District Assistance Questionnaire	Att5_District Assistance Qnr Items.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25

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	50	50
Annual IC Time Burden (Hours)	350	350
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Example screenshots (PERS: District Assistance Questionnaire)	Att8c-District Assistance Scrn Shot.docx	09/23/2022

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