Flood-Related Community Assessment for Public Health Emergency Response (CASPER) – WV, 2016

Community Assessment for Public Health Emergency Response (CASPER)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1036 can be found here:

Documents and Forms

Document Name Document Type
Flood-Related Community Assessment for Public Health Emergency Response (CASPER) – WV, 2016 Form and Instruction
WV Flood 2016 CASPER Questionnaire Flood CASPER Questions_clean.docx Form and Instruction
WV Flood 2016 CASPER Referral Form Referral Form_WV_Flood_clean.docx Form and Instruction
LOI_WVflood_CASPER_2016.pdf Letter of Invitation - West Virginia IC Document
AttachH_Burden Memo.docx Burden Request Memo IC Document
Signed OS RDF Undetermined Health Effects Among Persons Affected by Flooding_WV 2016.pdf Research Determination IC Document
G RqstAprvl 12052014 Clean_WV_final.docx CASPER GenIC - Request for Approval IC Document

Information Collection (IC) Details

IC Title:	Flood-Related Community Assessment for Public Health Emergency Response (CASPER) – WV, 2016	Agency IC Tracking Number:	0920-1036

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 and Instruction	NA	WV Flood 2016 CASPER Questionnaire	Flood CASPER Questions_clean.docx	NA	No		Paper Only
Form and Instruction	NA	WV Flood 2016 CASPER Referral Form	Referral Form_WV_Flood_clean.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 215	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	215	215
Annual IC Time Burden (Hours)	105	105
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Letter of Invitation - West Virginia	LOI_WVflood_CASPER_2016.pdf	07/21/2016
Burden Request Memo	AttachH_Burden Memo.docx	07/21/2016
Research Determination	Signed OS RDF Undetermined Health Effects Among Persons Affected by Flooding_WV 2016.pdf	07/21/2016
CASPER GenIC - Request for Approval	G RqstAprvl 12052014 Clean_WV_final.docx	07/21/2016

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