TA Feedback Form (individual)

[NCIPC] Evaluation of the Overdose Data to Action Technical Assistance Hub

Documents and Forms

Document Name Document Type
Form 0920-1355 TA Feedback Form (individual) Form and Instruction
0920-1355 TA Feedback Form – Individual TA Att. 3 Individual Technical Assistance Feedback Form.docx Form and Instruction
Att. 3a Screenshot_Individual Technical Assistance Feedback Form.pdf TA Feedback Form – Individual TA (screenshots) IC Document

Information Collection (IC) Details

IC Title:	TA Feedback Form (individual)	Agency IC Tracking Number:	0920-21BL

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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	0920-1355	TA Feedback Form – Individual TA	Att. 3 Individual Technical Assistance Feedback Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 618	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,236	-106	1,342
Annual IC Time Burden (Hours)	103	-9	112
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
TA Feedback Form – Individual TA (screenshots)	Att. 3a Screenshot_Individual Technical Assistance Feedback Form.pdf	09/26/2024

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