Information Collection

OD2A-LOCAL Evaluation & Performance Measurement Plan Template

IC 257748 under ICR 202301-0920-001 · OMB 0920-1283.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1283 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-n/a OD2A-LOCAL Evaluation & Performance Measurement Plan Template	Form and Instruction
0920-n/a OD2A-LOCAL Evaluation and Performance Measuring Plan Tem Attachment 3h_OD2A-LOCAL Evaluation and Performance Measurement Plan Template.docx	Form and Instruction
0920-n/a OD2A-LOCAL Evaluation and Performance Measuring Plan Tem Attachment 3h_OD2A-LOCAL Evaluation and Performance Measurement Plan Template.docx	Form and Instruction

IC Title:

OD2A-LOCAL Evaluation & Performance Measurement Plan Template

Agency IC Tracking Number:

0920-1283

Is this a Common Form? No

IC Status: New

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	0920-n/a	OD2A-LOCAL Evaluation and Performance Measuring Plan Template	Attachment 3h_OD2A-LOCAL Evaluation and Performance Measurement Plan Template.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	40	-26	66
Annual IC Time Burden (Hours)	14	-250	264
Annual IC Cost Burden (Dollars)	0	-8,802	8,802

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.