Information Collection

Intensive Complete Long-Term Evaluation

IC 251729 under ICR 202211-0920-008 · OMB 0920-0995.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0995 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Intensive Complete Long-Term Evaluation	Form and Instruction
Intensive Complete Long-Term Evaluation (paper option) Att 15_Intensive-Long Term Evaluation-2022- 11.22.22.docx	Form and Instruction
Intensive Complete Long-Term Evaluation (paper option) Att 15_Intensive-Long Term Evaluation-2022- 11.22.22.docx	Form and Instruction
Intensive Complete Long-Term Evaluation (electronic opti Att 16_ Intensive Long-Term Evaluation 2022- Screenshot.pdf	Form and Instruction
Intensive Complete Long-Term Evaluation (electronic opti Att 16_ Intensive Long-Term Evaluation 2022- Screenshot.pdf	Form and Instruction

IC Title:

Intensive Complete Long-Term Evaluation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	None	Intensive Complete Long-Term Evaluation (paper option)	Att 15_Intensive-Long Term Evaluation-2022- 11.22.22.docx		No		Paper Only
Form and Instruction	None	Intensive Complete Long-Term Evaluation (electronic option)	Att 16_ Intensive Long-Term Evaluation 2022- Screenshot.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 120

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	12	12
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.