ATSDR Technical Assistance (TA) Activity Form

APPLETREE Performance Measures

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0057 can be found here:

Documents and Forms

Document Name Document Type
ATSDR Technical Assistance (TA) Activity Form Form and Instruction
Att4b ATSDR TA Activity Form_Word_COVID-19 20200909.docx Other-WORD document to display instr
Technical Assist Details (screenshots) with COVID-19 que Att4b ATSDR TA Activity Form_SharePoint_COVID-19 20200909.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	ATSDR Technical Assistance (TA) Activity Form	Agency IC Tracking Number:

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	n/a	Technical Assist Details (screenshots) with COVID-19 question	Att4b ATSDR TA Activity Form_SharePoint_COVID-19 20200909.pdf		Yes	Yes	Fillable Fileable
Other-WORD document to display instrument content			Att4b ATSDR TA Activity Form_Word_COVID-19 20200909.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 28	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	420	420
Annual IC Time Burden (Hours)	35	35
Annual IC Cost Burden (Dollars)	1,305	1,305

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.