Information Collection

Att 7_Technical Assistance (TA) Satisfaction Instrument

IC 217676 under ICR 201507-0920-014 · OMB 0920-1099.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1099 can be found here:

Documents and Forms

Document Name Document Type
Att 7 TA_Instrument_wordversion.docx Other-WORD
Att 8 TA_Instrument_screenshot.docx Other-SCREENSHOTS
Att 10 TA_Intro_Email.docx Att 10_TA Intro Email IC Document
Att 12 TA_Reminder_Email.docx Att 12_TA Reminder Email IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att 7_Technical Assistance (TA) Satisfaction Instrument	Agency IC Tracking Number:	15NR

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			Att 7 TA_Instrument_wordversion.docx		Yes	Yes	Fillable Printable
Other-SCREENSHOTS			Att 8 TA_Instrument_screenshot.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,700	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 Agency Discretion
Annual Number of Responses for this IC	7,400	7,400
Annual IC Time Burden (Hours)	1,850	1,850
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 10_TA Intro Email	Att 10 TA_Intro_Email.docx	08/21/2015
Att 12_TA Reminder Email	Att 12 TA_Reminder_Email.docx	08/21/2015

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