Information Collection

Targeted and Intensive TA Assessment

IC 260189 under ICR 202507-0915-001 · OMB 0915-0391.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Targeted and Intensive TA Assessment	Form and Instruction
Form 5 Targeted and Intensive TA Assessment Targeted and Intensive TA Assessment	Form and Instruction
Form 5 (Redline) Targeted and Intensive TA Assessment Targeted and Intensive TA Assessment	Form and Instruction
5 Targeted and Intensive TA Assessment Form 5_Targeted and Intensive TA Assessment.docx	Form and Instruction
5 Targeted and Intensive TA Assessment Form 5_Targeted and Intensive TA Assessment.docx	Form and Instruction
5 (Redline) Targeted and Intensive TA Assessment Form 5_Targeted and Intensive TA Assessment 07102025 RL.docx	Form and Instruction
5 (Redline) Targeted and Intensive TA Assessment Form 5_Targeted and Intensive TA Assessment 07102025 RL.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	5				Yes	Yes	Fillable Fileable
Form and Instruction	5 (Redline)				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 120

Number of Respondents for Small Entity: 45

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	10	10
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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