ATSDR Technical Assistance (TA) Activity Form

[ATSDR] APPLETREE Performance Measures

Documents and Forms

Document Name Document Type
ATSDR Technical Assistance (TA) Activity Form Form and Instruction
Att4b1 ATSDR TA Form (WORD) 08212023.docx Other-WORD document to display instr
Att4b1 ATSDR TA Form (WORD) 08212023.docx Other-WORD document to display instr
Technical Assist Details (screenshots) Att4b ATSDR TA Form (ARMSS Screenshots) 08212023.pdf Form and Instruction
Technical Assist Details (screenshots) Att4b ATSDR TA Form (ARMSS Screenshots) 08212023.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)	Att4b ATSDR TA Form (ARMSS Screenshots) 08212023.pdf		Yes	Yes	Fillable Fileable
Other-WORD document to display instrument content			Att4b1 ATSDR TA Form (WORD) 08212023.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	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	510	90	420
Annual IC Time Burden (Hours)	34	-1	35
Annual IC Cost Burden (Dollars)	0	-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.