Information Collection

CHW Assessment

IC 266244 under ICR 202403-0990-008 · OMB 0990-0482.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 CHW Assessment	Form and Instruction
2 Community Health Worker Hands-on Experience CHW Assessment.pdf	Form and Instruction
2 Community Health Worker Hands-on Experience CHW Assessment.pdf	Form and Instruction

IC Title:

CHW Assessment

Agency IC Tracking Number:

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	2	Community Health Worker Hands-on Experience	CHW Assessment.pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	300	300
Annual IC Cost Burden (Dollars)	7,197	7,197

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.