Information Collection

Community Assessment Survey

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.