Information Collection

BE Review (Built Environment) Healthy Community Design: Assessment of Local Health and Planning Departments

IC 215612 under ICR 201412-0920-011 · 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⚠️ Notice: This information collection may be referencing outdated material.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
BE Review (Built Environment) Healthy Community Design: Assessment of Local Health and Planning Departments	Form and Instruction
LHD Instrument - Web B_LHD Instrument Web.docx	Form and Instruction
Planner Instrument E_Planner Instrument Web.docx	Form and Instruction
1 HGQ8-BE-REVIEW-SSA.docx Supporting Statement A	IC Document
2 HGQ8-BE-REVIEW-SSB.docx Supporting Statement B	IC Document
C_LHD Instrument Word.docx LHD Instrument - WORD	IC Document
D_Planner Instrument Word.docx Planner Instrument - WORD	IC Document
A_2004 Assessment Report.pdf 2004 Assessment Report	IC Document
F_APA Advance Email.docx APA Advance Email	IC Document
G_NACCHO Advance Email.docx NACCHO Advance Email	IC Document
H_Reminder Email_Non-response 10 Day APA.docx Reminder Email Non-Response 10 Day APA	IC Document
I_Reminder Email_Non-response 10 Days NACCHO.docx Reminder Emial Non-Response 10 Day NACCHO	IC Document
J_Reminder Email_Non-response 15 Day APA.docx Reminder Email Non-Response 15 Day APA	IC Document
K_Reminder Email_Non-response 15 Days NACCHO.docx Reminder Email Non-Response 15 Day NACCHO	IC Document
L_ Reminder Email 10 Days Partial APA.docx Reminder Email 10 Day Partial APA	IC Document
M_ Reminder Email 10 Days Partial NACCHO.docx Reminder Email 10 Day Partial NACCHO	IC Document
N_ Reminder Email 15 Days Partial APA.docx Reminder Email 15 Day Partial APA	IC Document
O_ Reminder Email 15 Days Partial NACCHO.docx Reminder Email 15 Day Partial NACCHO	IC Document

IC Title:

BE Review (Built Environment) Healthy Community Design: Assessment of Local Health and Planning Departments

Agency IC Tracking Number:

15SB

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 and Instruction	None	LHD Instrument - Web	B_LHD Instrument Web.docx	None	Yes	Yes	Fillable Fileable
Form and Instruction	None	Planner Instrument	E_Planner Instrument Web.docx	None	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,130

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	1,130	1,130
Annual IC Time Burden (Hours)	283	283
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	1 HGQ8-BE-REVIEW-SSA.docx	03/06/2015
Supporting Statement B	2 HGQ8-BE-REVIEW-SSB.docx	03/06/2015
LHD Instrument - WORD	C_LHD Instrument Word.docx	03/06/2015
Planner Instrument - WORD	D_Planner Instrument Word.docx	03/06/2015
2004 Assessment Report	A_2004 Assessment Report.pdf	03/06/2015
APA Advance Email	F_APA Advance Email.docx	03/06/2015
NACCHO Advance Email	G_NACCHO Advance Email.docx	03/06/2015
Reminder Email Non-Response 10 Day APA	H_Reminder Email_Non-response 10 Day APA.docx	03/06/2015
Reminder Emial Non-Response 10 Day NACCHO	I_Reminder Email_Non-response 10 Days NACCHO.docx	03/06/2015
Reminder Email Non-Response 15 Day APA	J_Reminder Email_Non-response 15 Day APA.docx	03/06/2015
Reminder Email Non-Response 15 Day NACCHO	K_Reminder Email_Non-response 15 Days NACCHO.docx	03/06/2015
Reminder Email 10 Day Partial APA	L_ Reminder Email 10 Days Partial APA.docx	03/06/2015
Reminder Email 10 Day Partial NACCHO	M_ Reminder Email 10 Days Partial NACCHO.docx	03/06/2015
Reminder Email 15 Day Partial APA	N_ Reminder Email 15 Days Partial APA.docx	03/06/2015
Reminder Email 15 Day Partial NACCHO	O_ Reminder Email 15 Days Partial NACCHO.docx	03/06/2015

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