Information Collection

BHW Performance Measures Forms

IC 206385 under ICR 202401-0915-003 · OMB 0915-0061.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 BHW Performance Measures Forms	Form and Instruction
Form 1 Performance Metrics 2023.pdf BHW Performance Measures Forms	Form and Instruction
0915-0061 - Appendix C - Program Mapping Document.pdf	Other-Program Mapping Document
0915-0061 - Appendix C - Program Mapping Document (updated).pdf	Other-Program Mapping Document
1 Performance Metrics 2023.pdf 0915-0061 - Appendix C - Performance Metrics - 2023.pdf	Form and Instruction
1 Performance Metrics 2023.pdf 0915-0061 - Appendix C - Performance Metrics - 2023 (updated).pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	1				Yes	Yes	Fillable Fileable
Other-Program Mapping Document					Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,882

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,882	252	1,630
Annual IC Time Burden (Hours)	5,929	527	5,402
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].