Performance Data: Quarterly Report Template

Implementation of an Internet & Paper-Based Uniform Data Set for OMH-funded Activities

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0275 can be found here:

Documents and Forms

Document Name Document Type
0990-0275 Copy of Performance Data Reporting_Template w PRA Language.xlsx Other-report

Information Collection (IC) Details

IC Title:	Performance Data: Quarterly Report Template	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Other-report			0990-0275 Copy of Performance Data Reporting_Template w PRA Language.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 130	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	520	520
Annual IC Time Burden (Hours)	390	390
Annual IC Cost Burden (Dollars)	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.