Information Collection

MULTI-SITE INSTRUMENT 3-Month Follow-Up (Assessment) - NOVA

IC 193033 under ICR 201005-0920-005 · OMB 0920-0863.

Documents and Forms

Document Name Document Type
10BA_Att 3F_3-Month_Follow-Up.doc Other-WORD

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	MULTI-SITE INSTRUMENT 3-Month Follow-Up (Assessment) - NOVA	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 241

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			10BA_Att 3F_3-Month_Follow-Up.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 192	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	192	192
Annual IC Time Burden (Hours)	192	192
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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