Information Collection

Standard Long-Term Evaluation

IC 251727 under ICR 202505-0920-002 · OMB 0920-0995.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Standard Long-Term Evaluation	Form and Instruction
Standard Long-Term Evaluation (paper option) Standard Long-Term Evaluation	Form and Instruction
Standard Long-Term Evaluation (electronic option) Standard Long-Term Evaluation	Form and Instruction
Standard Long-Term Evaluation (paper option) Att 11_Standard Long Term Evaluation-2022-11.22.22.docx	Form and Instruction
Standard Long-Term Evaluation (paper option) Att 11_Standard Long Term Evaluation-2022-11.22.22.docx	Form and Instruction
Standard Long-Term Evaluation (electronic option) Att 12_ Standard Long-Term Evaluation 2022-Screenshot.pdf	Form and Instruction
Standard Long-Term Evaluation (electronic option) Att 12_ Standard Long-Term Evaluation 2022-Screenshot.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	None				No		Paper Only
Form and Instruction	None				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	20	20
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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