Information Collection

Health Equity Capacity Assessment

IC 260627 under ICR 202305-0920-013 · OMB 0920-1412.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1412 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-23AA Health Equity Capacity Assessment	Form and Instruction
0920-23AA Att. 6a Health Equity Capacity Assessment Updated Att. 6a Health Equity Capacity Assessment Updated.pdf	Form and Instruction
0920-23AA Att. 6a Health Equity Capacity Assessment Updated Att. 6a Health Equity Capacity Assessment Updated.pdf	Form and Instruction

IC Title:

Health Equity Capacity Assessment

Agency IC Tracking Number:

0920-23AA

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	0920-23AA	Att. 6a Health Equity Capacity Assessment Updated	Att. 6a Health Equity Capacity Assessment Updated.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	5	5
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.