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Data Collection Checklist
Cultural and Linguistic Competency and Health Literacy Data Collection Checklist
OMB: 0915-0350
IC ID: 201621
OMB.report
HHS/HSA
OMB 0915-0350
ICR 201203-0915-002
IC 201621
( )
Documents and Forms
Document Name
Document Type
Form 1
Data Collection Checklist
Form and Instruction
1 Checklist
GPOM 2011-01 Culture and Health Literacy Checklist.pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Data Collection Checklist
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
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
1
Checklist
GPOM 2011-01 Culture and Health Literacy Checklist.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
900
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
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
900
0
900
0
0
0
Annual IC Time Burden (Hours)
900
0
900
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.