Information Collection

NSPHC Questionnaire

IC 200367 under ICR 201112-0920-003 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
NSPHC Questionnaire	Form
NSPHC Questionnaire Attachment F NSPHC Questionnaire.doc	Form
Attachment E NSPHC Introduction Letter.docx NSPHC Introduction Letter	IC Document

IC Title:

NSPHC Questionnaire

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	none	NSPHC Questionnaire	Attachment F NSPHC Questionnaire.doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	51	51
Annual IC Time Burden (Hours)	204	204
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
NSPHC Introduction Letter	Attachment E NSPHC Introduction Letter.docx	12/01/2011

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