Information Collection

Instrument 3: Plan, Do, Study, Act (PDSA) Form & Tracker

IC 257324 under ICR 202505-0970-013 · OMB 0970-0605.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Instrument 3_Plan, Do, Study, Act (PDSA) Form & Tracker.Clean.docx	Other-Form & Tracker
Instrument 3_Plan, Do, Study, Act (PDSA) Form & Tracker.Clean.docx	Other-Form & Tracker

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
Other-Form & Tracker					Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 168

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: 75 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,904	1,904
Annual IC Time Burden (Hours)	476	476
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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