View Information Collection (IC)

View Information Collection (IC)

IC Title:	Preventive Health and Health Services Block Grant Assessment	Agency IC Tracking Number:	0920-18AUV

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			Attachment D_Instrument Word Version.docx		No		Paper Only
Form	0920-XXXX	Preventive Health and Health Services Block Grant Assessment	Attachment E - Instrument Web Version.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	61	0	61	0	0	0
Annual IC Time Burden (Hours)	46	0	46	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Invitation Email	Attachment I - Invitation Email.docx	01/17/2019
Reminder Email	Attachment J - Reminder Email.docx	01/17/2019
Final Reminder Email	Attachment K - Final Reminder Email.docx	01/17/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.