Information Collection

Web-basedHWC Assessment

IC 216051 under ICR 201504-0920-004 · OMB 0920-1084.

Documents and Forms

Document Name Document Type
Web-basedHWC Assessment Form and Instruction
District Partner Assessment - HWC Att 6 DASH YMSM Web-based HWC Assessment.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Web-basedHWC Assessment	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 and Instruction	None	District Partner Assessment - HWC	Att 6 DASH YMSM Web-based HWC Assessment.docx	None	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.