Information Collection

WIC Local Agency Applications and State Agency Evaluations - SLT

IC 209949 under ICR 202302-0584-005 · OMB 0584-0591.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix H Gold Application and Instructions.pdf	Other-Appendix H: Gold Application a
Appendix I Gold Evaluation Instructions.docx	Other-Appendix I: Gold Evaluation In
Appendix J Gold Evaluation Instructions.pdf	Other-Appendix J: Gold Evaluation Wo
Appendix K Premiere and Elite Application and Instructions.pdf	Other-Appendix K: Premiere and Elite
Appendix L Premiere Elite Evaluation Instructions.pdf	Other-Appendix L: Premiere and Elite
Appendix M Premiere Elite Evaluation Worksheet.docx	Other-Appendix M: Premiere and Elite
Appendix N WIC Breastfeeding Award of Excellence Application Page.pdf	Other-Appendix N: WIC Breastfeeding

IC Title:

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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Appendix H: Gold Application and Instructions	Appendix H Gold Application and Instructions.pdf	Yes	Yes	Fillable Printable
Other-Appendix I: Gold Evaluation Instructions	Appendix I Gold Evaluation Instructions.docx	Yes	Yes	Fillable Printable
Other-Appendix J: Gold Evaluation Worksheet	Appendix J Gold Evaluation Instructions.pdf	Yes	Yes	Fillable Fileable
Other-Appendix K: Premiere and Elite Application and Instructions	Appendix K Premiere and Elite Application and Instructions.pdf	Yes	Yes	Fillable Printable
Other-Appendix L: Premiere and Elite Evaluation Instructions	Appendix L Premiere Elite Evaluation Instructions.pdf	Yes	Yes	Fillable Printable
Other-Appendix M: Premiere and Elite Evaluation Worksheet	Appendix M Premiere Elite Evaluation Worksheet.docx	Yes	Yes	Fillable Printable
Other-Appendix N: WIC Breastfeeding Award of Excellence Landing Page	Appendix N WIC Breastfeeding Award of Excellence Application Page.pdf	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 228

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
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	317	-28	345
Annual IC Time Burden (Hours)	492	-56	548
Annual IC Cost Burden (Dollars)	0	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.