Information Collection

Annual Progress Report

IC 191867 under ICR 202502-0920-014 · OMB 0920-0612.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Annual Progress Report	Form and Instruction
WISEWOMAN Annual Progress Report Annual Progress Report	Form and Instruction
Form 0920-0621 WISEWOMAN-MDE_Annual Progress Report Annual Progress Report	Form and Instruction
WISEWOMAN Annual Progress Report Att 5 Annual Progress Report.pdf	Form and Instruction
WISEWOMAN Annual Progress Report Att 5 Annual Progress Report.pdf	Form and Instruction
0920-0621 WISEWOMAN-MDE_Annual Progress Report Attachment 6 Annual Progress Report.pdf	Form and Instruction
0920-0621 WISEWOMAN-MDE_Annual Progress Report Attachment 6 Annual Progress Report.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-0612-23HT

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	None				Yes	Yes	Fillable Fileable
Form and Instruction	0920-0621			N/A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	640	640
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.

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