Information Collection

Success Stories Template

IC 272639 under ICR 202411-0920-015 · OMB 0920-1454.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1454 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-24FZ Success Stories Template Form
0920-24FZ Success Story Template Att 5c. Success Stories Template.docx Form
0920-24FZ Success Story Template Att 5c. Success Stories Template.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Success Stories Template	Agency IC Tracking Number:	090-24FZ

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	0920-24FZ	Success Story Template	Att 5c. Success Stories Template.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	55	55
Annual IC Time Burden (Hours)	55	55
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.