Information Collection

Assessment Evaluation - State Local Tribal Respondents

IC 185866 under ICR 202403-3320-002 · OMB 3320-0003.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3320-0003 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3320-0003 (A) Assessment Evaluation - State Local Tribal Respondents	Form and Instruction
3320-0003 (A) Assessment Evaluation Assessment Evaluation - Requester Questionnaire - 0003A.pdf	Form and Instruction
3320-0003 (A) Assessment Evaluation Assessment Evaluation - Requester Questionnaire - 0003A.pdf	Form and Instruction
Assessment Evaluation - Requester Questionnaire - 0003A - Electronic Screen Print.pdf Screen Print of Electronic Version	IC Document
Assessment Evaluation - Requester Questionnaire - 0003A - Electronic Screen Print.pdf Screen Print of Electronic Version	IC Document

IC Title:

Assessment Evaluation - State Local Tribal Respondents

Agency IC Tracking Number:

0003A

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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	3320-0003 (A)	Assessment Evaluation	Assessment Evaluation - Requester Questionnaire - 0003A.pdf		Yes	Yes	Fillable Fileable

Line of Business: Litigation and Judicial Activities

Subfunction: Resolution Facilitation

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: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	10	-90	100
Annual IC Time Burden (Hours)	1	-7	8
Annual IC Cost Burden (Dollars)	53	53	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Screen Print of Electronic Version	Assessment Evaluation - Requester Questionnaire - 0003A - Electronic Screen Print.pdf	03/13/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.