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TA Pilot Assessment
CDC Workplace Health Promotion Resource Center
OMB: 0920-1151
IC ID: 223226
OMB.report
HHS/CDC
OMB 0920-1151
ICR 201608-0920-015
IC 223226
( )
Documents and Forms
Document Name
Document Type
TA Pilot Assessment
Form
TA Pilot Assessment
Att D-8_TA Pilot Assessment Screenshots_8-5-16.docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
TA Pilot 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
none
TA Pilot Assessment
Att D-8_TA Pilot Assessment Screenshots_8-5-16.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
33
Number of Respondents for Small Entity:
26
Affected Public:
State, Local, and Tribal Governments
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
33
0
33
0
0
0
Annual IC Time Burden (Hours)
11
0
11
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.
