Information Collection

Readiness for Change Assessment

IC 233758 under ICR 202501-0935-001 · OMB 0935-0179.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Readiness for Change Assessment	Form and Instruction
Form 1 Readiness for Change Assessment Readiness for Change Assessment	Form and Instruction
1 Readiness for Change Assessment Attachment B_Readiness for Change Assessment_101818.docx	Form and Instruction
1 Readiness for Change Assessment Attachment B_Readiness for Change Assessment_101818.docx	Form and Instruction
Fast Track Submission_Readiness to Change Assessment_101818.doc Fast Track Supporting Statement	IC Document
Fast Track Submission_Readiness to Change Assessment_101818.doc Fast Track Supporting Statement	IC Document
Supporting Statement_101818.doc Total Overview	IC Document
Supporting Statement_101818.doc Total Overview	IC Document
Cover Page Rediness to Change.doc Cover Page	IC Document
Cover Page Rediness to Change.doc Cover Page	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: Removed

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	1				No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-18	18
Annual IC Time Burden (Hours)	-9	9
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast Track Supporting Statement		10/29/2018
Total Overview		10/29/2018
Cover Page		10/29/2018

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].