Information Collection

CHW Assessment

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.