Information Collection

Survey of Food Safety Programs Survey (paper) Local Health Departments

IC 210103 under ICR 201401-0920-006 · OMB 0920-1021.

Documents and Forms

Document Name Document Type
Att3_SurveyFSP_PaperSurvey__Clean..docx Other-WORD
Att 7 EFSPs_Fact Sheet.docx Att 7 EFSPs_Fact Sheet IC Document
Att 6 EFSPs_ Participation Request Email.docx Att 6 EFSPs_ Participation Request Email IC Document
Att 8 EFSPs_ Informed Consent Info Sheet.docx Att 8 EFSPs_ Informed Consent Info Sheet IC Document
Att 9a EFSPs_Cover Correspondence_PaperSurvey.doc Att 9a EFSPs_Cover Correspondence_PaperSurvey IC Document
Att 11 EFSPs Follow-up 1 Reminder Email.doc Att 11 EFSPs Follow-up 1 Reminder Email IC Document
Att 12 EFSPs_ Follow-up 2 Reminder Email.doc Att 12 EFSPs_ Follow-up 2 Reminder Email IC Document
Att 13 EFSPs_ Follow-up 3 Reminder Telephone Call.doc Att 13 EFSPs_ Follow-up 3 Reminder Telephone Call IC Document
Att 10 EFSPs _Telephone Script for Recruitment of Health Department.docx Att 10 EFSPs _Telephone Script for Recruitment of Health Department IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey of Food Safety Programs Survey (paper) Local Health Departments	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Other-WORD			Att3_SurveyFSP_PaperSurvey__Clean..docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 35	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	35	35
Annual IC Time Burden (Hours)	70	70
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 7 EFSPs_Fact Sheet	Att 7 EFSPs_Fact Sheet.docx	01/16/2014
Att 6 EFSPs_ Participation Request Email	Att 6 EFSPs_ Participation Request Email.docx	01/16/2014
Att 8 EFSPs_ Informed Consent Info Sheet	Att 8 EFSPs_ Informed Consent Info Sheet.docx	01/16/2014
Att 9a EFSPs_Cover Correspondence_PaperSurvey	Att 9a EFSPs_Cover Correspondence_PaperSurvey.doc	01/16/2014
Att 11 EFSPs Follow-up 1 Reminder Email	Att 11 EFSPs Follow-up 1 Reminder Email.doc	01/16/2014
Att 12 EFSPs_ Follow-up 2 Reminder Email	Att 12 EFSPs_ Follow-up 2 Reminder Email.doc	01/16/2014
Att 13 EFSPs_ Follow-up 3 Reminder Telephone Call	Att 13 EFSPs_ Follow-up 3 Reminder Telephone Call.doc	01/16/2014
Att 10 EFSPs _Telephone Script for Recruitment of Health Department	Att 10 EFSPs _Telephone Script for Recruitment of Health Department.docx	01/16/2014

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