Information Collection

State Survey

IC 194214 under ICR 201008-0930-004 · OMB 0930-0316.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0316 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachment 5-STOP State Survey	Form and Instruction
Attachment 5-STOP Attachment 5-STOP Act State Survey Attachment 5-STOP Act State Survey-6-10-10.pdf	Form and Instruction
Attachment 1-STOP Act State Report text-6-10-10.doc Attachment 1-STOP Act	IC Document
Attachment 2-STOP Act ICCPUD members 6-10-10.doc Attachment 2-STOP Act ICCPUD Members	IC Document
Attachment 3-STOP Act agency comments to FRN-6-14-10.pdf Attachment 3-Comments	IC Document
Attachment 4-STOP Act Stakeholder Consultants-6-6-10.doc Attachment 4-Stakeholder Consultants	IC Document
Attachment 6-Draft Cover Letter to Governors 6-10-10.doc Attachment 6-Draft Cover Letter to Governors	IC Document
Appendix A-STOP Act Categories-1.doc Appendix A-Stop Act Categories-1	IC Document

IC Title:

State Survey

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	Attachment 5-STOP Act State Survey	Attachment 5-STOP Act State Survey	Attachment 5-STOP Act State Survey-6-10-10.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

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	51	51
Annual IC Time Burden (Hours)	903	903
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 1-STOP Act	Attachment 1-STOP Act State Report text-6-10-10.doc	08/03/2010
Attachment 2-STOP Act ICCPUD Members	Attachment 2-STOP Act ICCPUD members 6-10-10.doc	08/03/2010
Attachment 3-Comments	Attachment 3-STOP Act agency comments to FRN-6-14-10.pdf	08/03/2010
Attachment 4-Stakeholder Consultants	Attachment 4-STOP Act Stakeholder Consultants-6-6-10.doc	08/03/2010
Attachment 6-Draft Cover Letter to Governors	Attachment 6-Draft Cover Letter to Governors 6-10-10.doc	08/03/2010
Appendix A-Stop Act Categories-1	Appendix A-STOP Act Categories-1.doc	10/12/2010

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