Implementation Feedback Form

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

Documents and Forms

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
Att. 6a Screenshot_Implementation Feedback Form.pdf Implementation Feedback Form (screenshots) IC Document

Information Collection (IC) Details

IC Title:	Implementation Feedback Form	Agency IC Tracking Number:	0920-1355

Is this a Common Form? No		IC Status: New

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	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 %

	Requested	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

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.