Information Collection

Sre

IC 191686 under ICR 200912-0930-004 · OMB 0930-0308.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Survey SRE	Form and Instruction
Survey Attachment A - Survey ATTACH_A_Final SSRE Questionnaire 10_27_09.doc	Form and Instruction
Attach B-G.zip Attachments B-G	IC Document

IC Title:

SRE

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	Survey	Attachment A - Survey	ATTACH_A_Final SSRE Questionnaire 10_27_09.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	4,500	4,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachments B-G	Attach B-G.zip	12/17/2009

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