Information Collection

LHD HAI/AR Strategy Pilot Feedback Form

IC 256304 under ICR 202210-0920-003 · OMB 0920-1394.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
LHD HAI/AR Strategy Pilot Feedback Form	Form and Instruction
Feedback Form Att 3a LHD HAIAR Strategy Pilot FEEDBACK FORM_final 8.30.22.docx	Form and Instruction
Feedback Form Att 3a LHD HAIAR Strategy Pilot FEEDBACK FORM_final 8.30.22.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-22GG

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	n/a	Feedback Form	Att 3a LHD HAIAR Strategy Pilot FEEDBACK FORM_final 8.30.22.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	240	240
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.