Information Collection

State Health Department Employees

IC 199553 under ICR 201307-0925-004 · OMB 0925-0649.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 State Health Department Employees	Form and Instruction
1 Health Department Script HCS_SSA_ATTACH 18_HEALTH DEPT SCRIPT_SEPTEMBER 2011 FINAL for OMB.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	1	Health Department Script	HCS_SSA_ATTACH 18_HEALTH DEPT SCRIPT_SEPTEMBER 2011 FINAL for OMB.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 17

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-17	17
Annual IC Time Burden (Hours)	-5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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