Information Collection

Survey of State and Territorial Asthma Program Evaluators

IC 199086 under ICR 201102-0920-005 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material.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
Survey of State and Territorial Asthma Program Evaluators Form
Web Survey of Asthma Program Evaluators Asthma ETA Attachment B- Data Collection Instrument Part 1&2 web version 081811.docx Form
Word version of Survey of Asthma Program Evaluators Asthma ETA Attachment C- Data Collection Instrument Part 1&2 Word version 081811.docx Form
Asthma ETA Attachment D - Introductory Email 081811.docx Att D - Intro Email IC Document
Asthma ETA Attachment E - Reminders 081811.docx Att E - Reminders IC Document
Asthma ETA Attachment F - follow up email 081811.docx Att F - Follow-up Email IC Document
Asthma ETA Attachment G- Evaluator Self Assessment Follow up 081811.docx Att G - Self-assessment follow-up IC Document
Asthma ETA Attachment H- Sample Report 081811.docx Att H - Sample reports IC Document
Asthma ETA Supporting Statement Part A 081118.docx Supporting Statement A IC Document
Asthma ETA Supporting Statement Part B 081811.docx Supporting Statement B IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey of State and Territorial Asthma Program Evaluators	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	Web Survey of Asthma Program Evaluators	Asthma ETA Attachment B- Data Collection Instrument Part 1&2 web version 081811.docx		Yes	Yes	Fillable Fileable
Form	none	Word version of Survey of Asthma Program Evaluators	Asthma ETA Attachment C- Data Collection Instrument Part 1&2 Word version 081811.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 36	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	36	0	0	0	0	0
Annual IC Time Burden (Hours)	18	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Att D - Intro Email	Asthma ETA Attachment D - Introductory Email 081811.docx	08/25/2011
Att E - Reminders	Asthma ETA Attachment E - Reminders 081811.docx	08/25/2011
Att F - Follow-up Email	Asthma ETA Attachment F - follow up email 081811.docx	08/25/2011
Att G - Self-assessment follow-up	Asthma ETA Attachment G- Evaluator Self Assessment Follow up 081811.docx	08/25/2011
Att H - Sample reports	Asthma ETA Attachment H- Sample Report 081811.docx	08/25/2011
Supporting Statement A	Asthma ETA Supporting Statement Part A 081118.docx	08/25/2011
Supporting Statement B	Asthma ETA Supporting Statement Part B 081811.docx	08/25/2011

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