Information Collection

CCRF_Georgia

IC 213373 under ICR 201311-0920-016 · OMB 0920-1011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CCRF_Georgia	Form
Case Investigation Appendix 1. CCHF_Case investigation questionnaire.doc	Form
KAP Survey Appendix 2. KAP Survey.docx	Form
Consent Appendix 3. Consent Form.docx	Form
LOI CCHF Investigation.pdf Letter of Invitation	IC Document
2015001_XXX CCHF_Georgia.docx EEI Request	IC Document

IC Title:

CCRF_Georgia

Agency IC Tracking Number:

15AK

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR USC 301 [241] (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	none	KAP Survey	Appendix 2. KAP Survey.docx	No	Paper Only
Form	none	Case Investigation	Appendix 1. CCHF_Case investigation questionnaire.doc	No	Paper Only
Form	none	Consent	Appendix 3. Consent Form.docx	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 830

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	830	830
Annual IC Time Burden (Hours)	303	303
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter of Invitation	LOI CCHF Investigation.pdf	10/03/2014
EEI Request	2015001_XXX CCHF_Georgia.docx	10/03/2014

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