Information Collection

Community Survey

IC 199728 under ICR 201110-0920-003 · OMB 0920-0908.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
REVISED_Attachment 3_CommunitySurvey_Nov 10 2011 Version.doc	Instruction
Attch6InfrastructureSurvey.docx Infrastructure Survey	IC Document

IC Title:

Community 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
Instruction			REVISED_Attachment 3_CommunitySurvey_Nov 10 2011 Version.doc		No		Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	16	16
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Infrastructure Survey	Attch6InfrastructureSurvey.docx	10/06/2011

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