Information Collection

Institutional Awareness and Commitment Survey (State Health Departments)

IC 210317 under ICR 201405-0920-009 · OMB 0920-1010.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1010 Institutional Awareness and Commitment Survey (State Health Departments)	Form and Instruction
0920-1010 ICR Attachment D old survey w-tracked changes ICR Attachment D old survey w-tracked changes.docx	Form and Instruction
0920-1010 Attachment D - Survey - New Attachment D - Survey - New.docx	Form and Instruction
Attachment E- Email Invitation.docx Attachment E- Email Invitation	IC Document
Attachment F - Email Invitation Follow-up.docx Attachment F - Email Invitation Follow-up	IC Document
Attachment C - Survey - Screenshots of new instrument.pdf Attachment C - Survey - Screenshots of new instrument	IC Document
ICRC Change Request Memo.docx ICRC Change Request Memo	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 and Instruction	0920-1010	ICR Attachment D old survey w-tracked changes	ICR Attachment D old survey w-tracked changes.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1010	Attachment D - Survey - New	Attachment D - Survey - New.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8

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	Previously Approved
Annual Number of Responses for this IC	8	8
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment E- Email Invitation	Attachment E- Email Invitation.docx	02/06/2014
Attachment F - Email Invitation Follow-up	Attachment F - Email Invitation Follow-up.docx	02/06/2014
Attachment C - Survey - Screenshots of new instrument	Attachment C - Survey - Screenshots of new instrument.pdf	05/19/2014
ICRC Change Request Memo	ICRC Change Request Memo.docx	05/19/2014

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