Web-Based Data Collection Tool Question Pool

Maternal Health Portfolio Evaluation

Documents and Forms

Document Name Document Type
Attachment B3_Web-Based Data Collection Tool-Cross-Cutting_2023.docx Other-Survey
Attachment B3_Web-Based Data Collection Tool-Cross-Cutting_2023.docx Other-Survey

Information Collection (IC) Details

IC Title:	Web-Based Data Collection Tool Question Pool	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-Survey			Attachment B3_Web-Based Data Collection Tool-Cross-Cutting_2023.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12	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	12	-3	15
Annual IC Time Burden (Hours)	6	-2	8
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.