Information Collection

Implementation Capacity Rubric

IC 249946 under ICR 202506-0920-006 · OMB 0920-1365.

Documents and Forms

Document Name Document Type
Form 0920-1365 Implementation Capacity Rubric Form
Form 0920-1365 ImplementCapRubric_CoreSIPP Implementation Capacity Rubric Form
0920-1365 ImplementCapRubric_CoreSIPP Att E_ImplementCapRubric_CoreSIPP.docx Form
0920-1365 ImplementCapRubric_CoreSIPP Att E_ImplementCapRubric_CoreSIPP.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Implementation Capacity Rubric	Agency IC Tracking Number:	0920-1365

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-1365	ImplementCapRubric_CoreSIPP	Att E_ImplementCapRubric_CoreSIPP.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 26	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	26	3	23
Annual IC Time Burden (Hours)	52	6	46
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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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