Information Collection

Eval Assessment TBC Partner Interview Guide WW (Attachment 3k)

IC 272064 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 0920-24FI Eval Assessment TBC Partner Interview Guide WW (Attachment 3k) Form and Instruction
0920-24FI In-Depth Assessment – Evaluability Assessment Recipient Att 3k. Eval Assessment_TBC_Partner_Interview Guide_WW.docx Form and Instruction
0920-24FI In-Depth Assessment – Evaluability Assessment Recipient Att 3k. Eval Assessment_TBC_Partner_Interview Guide_WW.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Eval Assessment TBC Partner Interview Guide WW (Attachment 3k)	Agency IC Tracking Number:	0920-24FI

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	0920-24FI	In-Depth Assessment â Evaluability Assessment Recipient Interview Guide â Clinical Quality Measure â WISEWOMAN	Att 3k. Eval Assessment_TBC_Partner_Interview Guide_WW.docx		Yes	Yes	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: 100 %

	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

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