Information Collection

Local Public Health System Performance Assessment Instrument

IC 7006 under ICR 201007-0920-008 · OMB 0920-0555.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Local Public Health System Performance Assessment Instrument	Form and Instruction
1 Local Public Health System Performance Assessment Instru Att E.1_Local Assmt Instr.pdf	Form and Instruction
Att E.2_Local RIF.pdf Att E	IC Document
Att E.3_Local Priority.pdf Att E	IC Document
Att E.4_Local Agency Contribution.pdf Att E	IC Document
Att F_Mtg Guide.doc Att F_Mtg Guide	IC Document
Att G_ Data Entry Instructions_1007.docx Att G_ Data Entry Instructions_1007	IC Document
Att H_Screen Shots_Web Based System.docx Att H_Screen Shots_Web Based System	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	1	Local Public Health System Performance Assessment Instrument	Att E.1_Local Assmt Instr.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 350

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	Previously Approved
Annual Number of Responses for this IC	350	350
Annual IC Time Burden (Hours)	5,600	5,600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att E	Att E.2_Local RIF.pdf	07/15/2010
Att E	Att E.3_Local Priority.pdf	07/15/2010
Att E	Att E.4_Local Agency Contribution.pdf	07/15/2010
Att F_Mtg Guide	Att F_Mtg Guide.doc	07/15/2010
Att G_ Data Entry Instructions_1007	Att G_ Data Entry Instructions_1007.docx	07/15/2010
Att H_Screen Shots_Web Based System	Att H_Screen Shots_Web Based System.docx	07/15/2010

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