Information Collection

Ex Assessment CQM Recipient Interview Guide_WW (Attachment 4c)

IC 271844 under ICR 202504-0920-030 · OMB 0920-1453.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1453 Ex Assessment CQM Recipient Interview Guide_WW (Attachment 4c)	Form and Instruction
Form 0920-1453 Att 4c. Ex Assessment_CQM_Recipient_Interview Guide_WW_rev 2025 Ex Assessment CQM Recipient Interview Guide_WW (Attachment 4c)	Form and Instruction
0920-1453 Att 4c. Ex Assessment_CQM_Recipient_Interview Guide_WW_r Att 4c. Ex Assessment_CQM_Recipient_Interview Guide_WW_clean.docx	Form and Instruction
0920-1453 Att 4c. Ex Assessment_CQM_Recipient_Interview Guide_WW_r Att 4c. Ex Assessment_CQM_Recipient_Interview Guide_WW_clean.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	0920-1453			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: 2

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	Previously Approved
Annual Number of Responses for this IC	2	2
Annual IC Time Burden (Hours)	3	3
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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