MUH Operator Baseline Survey (LA County)

Adoption, Health Impact and Cost of Smoke-Free Multi-Unit Housing Policies

Documents and Forms

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

Information Collection (IC) Details

IC Title:	MUH Operator Baseline Survey (LA County)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	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 %

	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

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.