Annual Progress Report

[NCCDPHP] Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Reporting System

Documents and Forms

Document Name Document Type
Annual Progress Report Form and Instruction
WISEWOMAN Annual Progress Report Att 5 Annual Progress Report.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Annual Progress Report	Agency IC Tracking Number:	0920-0612-23HT

Is this a Common Form? No		IC Status: Modified

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	None	WISEWOMAN Annual Progress Report	Att 5 Annual Progress Report.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	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	Previously Approved
Annual Number of Responses for this IC	40	5	35
Annual IC Time Burden (Hours)	640	80	560
Annual IC Cost Burden (Dollars)	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.