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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.