OMB
.report
Search
CHW Assessment
National Hypertension Control Initiative
OMB: 0990-0482
IC ID: 266244
OMB.report
HHS/HHSDM
OMB 0990-0482
ICR 202403-0990-008
IC 266244
( )
Documents and Forms
Document Name
Document Type
Form 2
CHW Assessment
Form and Instruction
2 Community Health Worker Hands-on Experience
CHW Assessment.pdf
Form and Instruction
2 Community Health Worker Hands-on Experience
CHW Assessment.pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
CHW Assessment
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Mandatory
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
2
Community Health Worker Hands-on Experience
CHW Assessment.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Community and Social Services
Subfunction:
Social Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
300
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
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
300
0
300
0
0
0
Annual IC Time Burden (Hours)
300
0
300
0
0
0
Annual IC Cost Burden (Dollars)
7,197
0
7,197
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.