Needs and Perceptions of Did You Know

Surveys of State, Tribal, Local and Territorial (STLT) Governmental Health Agencies

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Document Name Document Type
Needs and Perceptions of Did You Know Form
DYK_ATTACH-C_Web_Survey_2011-08-03.docx Other-Screen Shots Web Survey
Consent & Survey DYK_ATTACH-B_Word_Survey_2011-08-036.docx Form
DYK_Supporting_Statement_PART-A_2011-08-03.docx Supporting Statement A IC Document
DYK_Supporting_Statement_PART-B_2011-08-03.docx Supporting Statement B IC Document
DYK_ATTACH-D_Survey_Notification_Email_2011-08-03.docx Survey Notification Email IC Document
DYK_ATTACH-E_Survey_Reminder_Email_2011-08-03.docx Survey Reminder Email IC Document
DYK_ATTACH-A_DYK_Samples_2011-08-03.docx Samples IC Document

Information Collection (IC) Details

IC Title:	Needs and Perceptions of Did You Know	Agency IC Tracking Number:

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	none	Consent & Survey	DYK_ATTACH-B_Word_Survey_2011-08-036.docx		Yes	Yes	Fillable Fileable
Other-Screen Shots Web Survey			DYK_ATTACH-C_Web_Survey_2011-08-03.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	500	0	0	0	0	0
Annual IC Time Burden (Hours)	125	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	DYK_Supporting_Statement_PART-A_2011-08-03.docx	08/04/2011
Supporting Statement B	DYK_Supporting_Statement_PART-B_2011-08-03.docx	08/04/2011
Survey Notification Email	DYK_ATTACH-D_Survey_Notification_Email_2011-08-03.docx	08/04/2011
Survey Reminder Email	DYK_ATTACH-E_Survey_Reminder_Email_2011-08-03.docx	08/04/2011
Samples	DYK_ATTACH-A_DYK_Samples_2011-08-03.docx	08/04/2011

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