Information Collection

Implementation Capacity Rubric

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-1365				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 %

table that charts list of burden
	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

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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