Information Collection

Implementation Feedback Form

IC 271204 under ICR 202409-0920-011 · OMB 0920-1355.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1355 Implementation Feedback Form	Form and Instruction
0920-1355 Implementation Feedback Form Att. 6 Implementation Feedback Form.docx	Form and Instruction
0920-1355 Implementation Feedback Form Att. 6 Implementation Feedback Form.docx	Form and Instruction
Att. 6a Screenshot_Implementation Feedback Form.pdf Implementation Feedback Form (screenshots)	IC Document
Att. 6a Screenshot_Implementation Feedback Form.pdf Implementation Feedback Form (screenshots)	IC Document

IC Title:

Agency IC Tracking Number:

0920-1355

Is this a Common Form? No

IC Status: New

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	0920-1355	Implementation Feedback Form	Att. 6 Implementation 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: 18

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	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	18	-1,216	1,234
Annual IC Time Burden (Hours)	5	-98	103
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Implementation Feedback Form (screenshots)	Att. 6a Screenshot_Implementation Feedback Form.pdf	09/26/2024

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