Information Collection

Community Assessment Survey

IC 180111 under ICR 200705-0920-004 · OMB 0920-0749.

Documents and Forms

Document Name Document Type
Community Assessment Survey Form and Instruction
Community Assessment Survey Appendix D. Community survey 4_11_2007-IA.doc Form and Instruction
Appendix I. Script for obtaining consent from the village leaders 4_2007.doc Script for Obtaining Consent from the Village Leaders IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Community Assessment Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Form and Instruction	None	Community Assessment Survey	Appendix D. Community survey 4_11_2007-IA.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Script for Obtaining Consent from the Village Leaders	Appendix I. Script for obtaining consent from the village leaders 4_2007.doc	04/26/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.