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Grantee Program staff-Tier 1 C/D and Ter 2/PREIS
ACYF Pregnancy Prevention Performance Measure Collection
OMB: 0990-0392
IC ID: 199779
OMB.report
HHS/HHSDM
OMB 0990-0392
ICR 201305-0990-001
IC 199779
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0392 can be found here:
2015-04-29 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
0990-PM OMB ICR Instrument 4 Reporting Form CD Grantees 8-4.docx
Other-Performance Measure reporting
0990-0392 Appendix D Example of Evaluation Grantee Consent 5 1 2012 (2).doc
0990-0392 Appendix D Example of Evaluation Grantee Consent 5 1 2012 (2)
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Grantee Program staff-Tier 1 C/D and Ter 2/PREIS
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
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-Performance Measure reporting form
0990-PM OMB ICR Instrument 4 Reporting Form CD Grantees 8-4.docx
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
48
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
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
48
0
0
0
0
48
Annual IC Time Burden (Hours)
1,008
0
0
0
0
1,008
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
0990-0392 Appendix D Example of Evaluation Grantee Consent 5 1 2012 (2)
0990-0392 Appendix D Example of Evaluation Grantee Consent 5 1 2012 (2).doc
05/09/2012
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.