Waterborne Disease Prevention: State Program Assessment

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⚠️ Notice: This information collection may be referencing outdated material.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
Attachment B-Interview Guide.docx Instruction
WDP-CAP-SSA.docx Supporting Statement A IC Document
WDP-CAP-SSB.docx Supporting Statement B IC Document
Attachment A-List of States.docx List of States IC Document
Attachment C-Introductory Email.docx Intro email IC Document
Attachment D-Email Reminder.docx Reminder email IC Document
Attachment E-Confirmation Email.docx Confirmation email IC Document
Attachment F-Follow up email.docx Follow-up email IC Document

Information Collection (IC) Details

IC Title:	Waterborne Disease Prevention: State Program Assessment	Agency IC Tracking Number:	15BGO

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
Instruction			Attachment B-Interview Guide.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 28	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	28	28
Annual IC Time Burden (Hours)	28	28
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	WDP-CAP-SSA.docx	09/28/2015
Supporting Statement B	WDP-CAP-SSB.docx	09/28/2015
List of States	Attachment A-List of States.docx	09/28/2015
Intro email	Attachment C-Introductory Email.docx	09/28/2015
Reminder email	Attachment D-Email Reminder.docx	09/28/2015
Confirmation email	Attachment E-Confirmation Email.docx	09/28/2015
Follow-up email	Attachment F-Follow up email.docx	09/28/2015

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