Assessment of Local Health Departments' Interventions to Address TB among Persons Experiencing Homelessness

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⚠️ Notice: This information collection may be referencing outdated material.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
Assessment of Local Health Departments' Interventions to Address TB among Persons Experiencing Homelessness Form
Health Department Homeless TB Data Collection Instrument ATTACHMENT B TB Homeless Instrument- Word v81313.docx Form
Health Department Homeless TB Data Collection Instrument ATTACHMENT C TB Homeless Instrument-Web.docx Form
ATTACHMENT A TB Homeless Council Recommendations v81313.docx ATTACHMENT A TB Homeless Council Recommendations v81313 IC Document
ATTACHMENT D County state homeless 2009-2011.xlsx ATTACHMENT D County state homeless 2009-2011 IC Document
ATTACHMENT E Advance Notification Email.docx ATTACHMENT E Advance Notification Email IC Document
ATTACHMENT F Notification Email.docx ATTACHMENT F Notification Email IC Document
ATTACHMENT G Reminder Email.docx ATTACHMENT G Reminder Email IC Document
Supporting Statement A_amended 9_5_13_TB among homeless.docx Supporting Statement A_amended 9_5_13_TB among homeless IC Document
Supporting Statement B_TB homeless.docx Supporting Statement B_TB homeless IC Document

Information Collection (IC) Details

IC Title:	Assessment of Local Health Departments' Interventions to Address TB among Persons Experiencing Homelessness	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	Health Department Homeless TB Data Collection Instrument	ATTACHMENT B TB Homeless Instrument- Word v81313.docx		Yes	Yes	Fillable Fileable
Form	None	Health Department Homeless TB Data Collection Instrument--Screenshots	ATTACHMENT C TB Homeless Instrument-Web.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 220	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	220	0	0	0	0	0
Annual IC Time Burden (Hours)	73	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
ATTACHMENT A TB Homeless Council Recommendations v81313	ATTACHMENT A TB Homeless Council Recommendations v81313.docx	09/05/2013
ATTACHMENT D County state homeless 2009-2011	ATTACHMENT D County state homeless 2009-2011.xlsx	09/05/2013
ATTACHMENT E Advance Notification Email	ATTACHMENT E Advance Notification Email.docx	09/05/2013
ATTACHMENT F Notification Email	ATTACHMENT F Notification Email.docx	09/05/2013
ATTACHMENT G Reminder Email	ATTACHMENT G Reminder Email.docx	09/05/2013
Supporting Statement A_amended 9_5_13_TB among homeless	Supporting Statement A_amended 9_5_13_TB among homeless.docx	09/05/2013
Supporting Statement B_TB homeless	Supporting Statement B_TB homeless.docx	09/05/2013

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