Information Collection

Survey of Food Safety Program (electronic) Local Health Departments

IC 210104 under ICR 201401-0920-006 · OMB 0920-1021.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 4 EFSPSurvey_Electronic(Screenshots).revised12202013.docx	Other-WORD
Att 6 EFSPs_ Participation Request Email.docx Att 6 EFSPs_ Participation Request Email	IC Document
Att 7 EFSPs_Fact Sheet.docx Att 7 EFSPs_Fact Sheet	IC Document
Att 8 EFSPs_ Informed Consent Info Sheet.docx Att 8 EFSPs_ Informed Consent Info Sheet	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
Att 9b EFSPs_Cover Correspondence_ElectronicSurvey.doc Att 9b EFSPs_Cover Correspondence_ElectronicSurvey	IC Document

IC Title:

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
Other-WORD			Att 4 EFSPSurvey_Electronic(Screenshots).revised12202013.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 138

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	138	138
Annual IC Time Burden (Hours)	276	276
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 6 EFSPs_ Participation Request Email	Att 6 EFSPs_ Participation Request Email.docx	01/16/2014
Att 7 EFSPs_Fact Sheet	Att 7 EFSPs_Fact Sheet.docx	01/16/2014
Att 8 EFSPs_ Informed Consent Info Sheet	Att 8 EFSPs_ Informed Consent Info Sheet.docx	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
Att 9b EFSPs_Cover Correspondence_ElectronicSurvey	Att 9b EFSPs_Cover Correspondence_ElectronicSurvey.doc	01/16/2014

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