Information Collection

Interview with Community Health Representatives

IC 197467 under ICR 201104-0920-017 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Interview with Community Health Representatives	Form and Instruction
Community Representative Interview Guide Att C-1. Community Reps_Interview Guide.doc	Form and Instruction
Att C-3. Community Reps_Consent Form.doc Community Representative Consent	IC Document
Att C-2. Community Reps_Information Sheet.doc Att C2 - Community Representative Information Sheet	IC Document

IC Title:

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	none	Community Representative Interview Guide	Att C-1. Community Reps_Interview Guide.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Community Representative Consent	Att C-3. Community Reps_Consent Form.doc	04/13/2011
Att C2 - Community Representative Information Sheet	Att C-2. Community Reps_Information Sheet.doc	04/13/2011

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