Information Collection

MUH Operator Baseline Survey (LA County)

IC 204437 under ICR 201309-0920-011 · OMB 0920-1004.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MUH Operator Baseline Survey (LA County)	Form
MUH Operator Baseline Survey clean 12.17.13 Att 6A(e) Baseline Operator Survey_9.3.13.doc	Form
Att 6A-1(e) MUH Operator Consent LA_9.3.13.docx Consent LA	IC Document

IC Title:

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	none	MUH Operator Baseline Survey	clean 12.17.13 Att 6A(e) Baseline Operator Survey_9.3.13.doc		No	No	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 130

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	130	130
Annual IC Time Burden (Hours)	163	163
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent LA	Att 6A-1(e) MUH Operator Consent LA_9.3.13.docx	09/23/2013

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