Information Collection

Effective Educational Campaigns for Private Well Owners

IC 211589 under ICR 201402-0920-018 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.