Information Collection

Annual Evaluation Survey-PHA

IC 275739 under ICR 202506-0920-007 · OMB 0920-1461.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1461 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-25AC Annual Evaluation Survey-PHA	Form
Form 0920-25AC ORS Annual Evaluation Survey- PHA Annual Evaluation Survey-PHA	Form
0920-25AC ORS Annual Evaluation Survey- PHA Att D_ORS Annual Evaluation Survey- PHA.docx	Form
0920-25AC ORS Annual Evaluation Survey- PHA Att D_ORS Annual Evaluation Survey- PHA.docx	Form

IC Title:

Annual Evaluation Survey-PHA

Agency IC Tracking Number:

0920-25AC

Is this a Common Form? No

IC Status: New

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	0920-25AC				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 61

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	61	61
Annual IC Time Burden (Hours)	31	31
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].