Public Health AmeriCorps Grantee Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Documents and Forms

Document Name Document Type
Form 1 Public Health AmeriCorps Grantee Survey Form and Instruction
1 Public Health AmeriCorps Grantee Survey PublicHealthAmeriCorps grantee survey instrument_5.20.23 OMB.docx www.americorps.gov Form and Instruction
Generic Clearance Submission_PHA Evaluation_Grantee Survey_.docx Public Health AmeriCorps Grantee Survey IC Document

Information Collection (IC) Details

IC Title:	Public Health AmeriCorps Grantee Survey	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 12501

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Public Health AmeriCorps Grantee Survey	PublicHealthAmeriCorps grantee survey instrument_5.20.23 OMB.docx	www.americorps.gov	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 82	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	82	82
Annual IC Time Burden (Hours)	41	41
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Public Health AmeriCorps Grantee Survey	Generic Clearance Submission_PHA Evaluation_Grantee Survey_.docx	05/30/2023

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