Effective Educational Campaigns for Private Well Owners

Information Collections to Advance State, Tribal, Local and Territorial (STLT) Governmental Agency System Performance, Capacity, and Program Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Document Name Document Type
Effective Educational Campaigns for Private Well Owners Form
Survey screenshots Wells_B_Instrument_Web.docx Form
Wells_SSA.docx Supporting Statement A IC Document
Wells_SSB.docx Supporting Statement B IC Document
Wells_A_Instrument_Word.docx Survey - Word IC Document
Wells_C_State List.docx List of Participating States IC Document
Wells_D_Initial E-mail.docx Initial Email IC Document
Wells_E_Instructions.docx Instructions IC Document
Wells_F_Reminder.docx Reminder Email IC Document
Wells_G_Phone Call.docx Phone call IC Document

Information Collection (IC) Details

IC Title:	Effective Educational Campaigns for Private Well Owners	Agency IC Tracking Number:

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
Form	none	Survey screenshots	Wells_B_Instrument_Web.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	Wells_SSA.docx	05/13/2014
Supporting Statement B	Wells_SSB.docx	05/13/2014
Survey - Word	Wells_A_Instrument_Word.docx	05/13/2014
List of Participating States	Wells_C_State List.docx	05/13/2014
Initial Email	Wells_D_Initial E-mail.docx	05/13/2014
Instructions	Wells_E_Instructions.docx	05/13/2014
Reminder Email	Wells_F_Reminder.docx	05/13/2014
Phone call	Wells_G_Phone Call.docx	05/13/2014

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