Information Collection

State and Community Awardee Performance Measure Reporting Tool

IC 213097 under ICR 201409-0920-009 · OMB 0920-0952.

Documents and Forms

Document Name Document Type
State and Community Awardee Performance Measure Reporting Tool Form
State and Community Awardee Performance Measure Reportin Att 6 (rev2) State and Community Awardee Performance Measure Reporting Tool.docx Form
0920-0952 Change Request 14AUG2014_REV 10SEPT2014.docx Justification for Change Request IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State and Community Awardee Performance Measure Reporting Tool	Agency IC Tracking Number:

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
Form	None	State and Community Awardee Performance Measure Reporting Tool	Att 6 (rev2) State and Community Awardee Performance Measure Reporting Tool.docx	None	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	163	163
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Justification for Change Request	0920-0952 Change Request 14AUG2014_REV 10SEPT2014.docx	09/12/2014

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