Information Collection

Eval Assessment TBC Recipient Interview Guide WW (Attachment 3i)

IC 271840 under ICR 202410-0920-005 · OMB 0920-1453.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1453 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-24FI Eval Assessment TBC Recipient Interview Guide WW (Attachment 3i)	Form and Instruction
0920-24FI In-Depth Assessment – Evaluability Assessment Recipient Att 3i. Eval Assessment_TBC_Recipient_Interview Guide_WW.docx	Form and Instruction
0920-24FI In-Depth Assessment – Evaluability Assessment Recipient Att 3i. Eval Assessment_TBC_Recipient_Interview Guide_WW.docx	Form and Instruction

IC Title:

Eval Assessment TBC Recipient Interview Guide WW (Attachment 3i)

Agency IC Tracking Number:

0920-24FI

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	0920-24FI	In-Depth Assessment â Evaluability Assessment Recipient Interview Guide â Team-Based Care â WISEWOMAN	Att 3i. Eval Assessment_TBC_Recipient_Interview Guide_WW.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3	3
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.