Information Collection

Provider - State/Tribal - Stakeholder

IC 208304 under ICR 201308-0930-001 · OMB 0930-0286.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0286 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form E. RNS Instrument Provider - State/Tribal - Stakeholder	Form and Instruction
E. RNS Instrument E. RNS Instrument and Verbal Consent Script.docx E. RNS Instrument and Verbal Consent Script.docx	Form and Instruction
G. Coalition Surve G. Coalition Survey Instrument and Web Consent.docx G. Coalition Survey Instrument and Web Consent.docx	Form and Instruction

IC Title:

Provider - State/Tribal - Stakeholder

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 and Instruction	E. RNS Instrument and Verbal Consent Script.docx	E. RNS Instrument and Verbal Consent Script.docx	E. RNS Instrument and Verbal Consent Script.docx		Yes	Yes	Fillable Fileable
Form and Instruction	G. Coalition Survey Instrument and Web Consent	G. Coalition Survey Instrument and Web Consent.docx	G. Coalition Survey Instrument and Web Consent.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,852

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,852	1,852
Annual IC Time Burden (Hours)	1,242	1,242
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.