Information Collection

State Survey

IC 194214 under ICR 201209-0930-001 · OMB 0930-0316.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0316 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form State Survey State Survey	Form and Instruction
State Survey State Survey Attachment 3- 2013 STOP Act Survey with OMB edits 02 08 13.docx	Form and Instruction
Attachment 2 - ICCPUD Principals List.docx ICCPUD Principals List	IC Document
Attachment 1 - STOP Act as enacted Dec. 20, 2006.rtf STOP Act	IC Document
Attachment 4 - Sample data tables for AL and AK.doc Sample data tables for AL and AK	IC Document
Attachment 5 - Sample Letter to Governors.docx Sample Letter to Governors	IC Document

IC Title:

State Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	State Survey	State Survey	Attachment 3- 2013 STOP Act Survey with OMB edits 02 08 13.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

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: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	903	903
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ICCPUD Principals List	Attachment 2 - ICCPUD Principals List.docx	08/24/2012
STOP Act	Attachment 1 - STOP Act as enacted Dec. 20, 2006.rtf	08/24/2012
Sample data tables for AL and AK	Attachment 4 - Sample data tables for AL and AK.doc	08/24/2012
Sample Letter to Governors	Attachment 5 - Sample Letter to Governors.docx	08/24/2012

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