CBS Survey

Pilot Study of Community-Based Surveillance of Supports for Healthy Eating/Active Living (HE/AL)

Documents and Forms

Document Name Document Type
CBS Survey Form
CBS Questionnaire Appendix C1. CBS Questionnaire 01_19_12.doc Form
Survey Screenshots Appendix C2. CBS Survey Screen Shots 11712.pdf Form
Appendix D5. Instructions 01_19_12.doc Survey Instructions IC Document

Information Collection (IC) Details

IC Title:	CBS Survey	Agency IC Tracking Number:

Is this a Common Form? No		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	CBS Questionnaire	Appendix C1. CBS Questionnaire 01_19_12.doc		Yes	Yes	Fillable Fileable
Form	none	Survey Screenshots	Appendix C2. CBS Survey Screen Shots 11712.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	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 Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Survey Instructions	Appendix D5. Instructions 01_19_12.doc	01/24/2012

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