Information Collection

State Self-Assessment Review and Report

IC 10062 under ICR 202504-0970-013 · OMB 0970-0223.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 State Self-Assessment Review and Report	Form and Instruction
Form 1 CSE Program Self-Assessment Report State Self-Assessment Review and Report	Form and Instruction
1 CSE Program Self-Assessment Report SAR Reporting Format and Instructions -0970-0223_clean updated 3.11.25.docx	Form and Instruction
1 CSE Program Self-Assessment Report SAR Reporting Format and Instructions -0970-0223_clean updated 3.11.25.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 308

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				Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

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	Previously Approved
Annual Number of Responses for this IC	54	54
Annual IC Time Burden (Hours)	432	432
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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