Community Health Status Indicators (CHSI) 2015: Awareness, Use, and Benefits 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 16ADY Community Health Status Indicators (CHSI) 2015: Awareness, Use, and Benefits Assessment Form and Instruction
16ADY B. Health Director Referral Instrument_CHSI B. Health Director Referral Instrument_CHSI.docx Form and Instruction
16ADY C. Focus Group Participant Recruitment Instrument_CHSI C. Focus Group Participant Recruitment Instrument_CHSI.docx Form and Instruction
16ADY D. Focus Group Interview Guide Instrument_CHSI D. Focus Group Interview Guide Instrument_CHSI.docx Form and Instruction
A. Targeted Local Health Departments_CHSI.docx A. Targeted Local Health Departments_CHSI IC Document
E. Contact Reminder Call_CHSI.docx E. Contact Reminder Call_CHSI IC Document
F. Focus Group Scheduling Call_CHSI.docx F. Focus Group Scheduling Call_CHSI IC Document
G. Focus Group Confirmation Email_CHSI.docx G. Focus Group Confirmation Email_CHSI IC Document
H. Focus Group Confirmation Call_CHSI.docx H. Focus Group Confirmation Call_CHSI IC Document
CHSI-EVAL-SSA.docx SSA CHSI-EVAL IC Document
CHSI-EVAL-SSB.docx SSB CHSI-EVAL IC Document

Information Collection (IC) Details

IC Title:	Community Health Status Indicators (CHSI) 2015: Awareness, Use, and Benefits Assessment	Agency IC Tracking Number:	16ADY

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	16ADY	B. Health Director Referral Instrument_CHSI	B. Health Director Referral Instrument_CHSI.docx	No	Fillable Printable
Form and Instruction	16ADY	C. Focus Group Participant Recruitment Instrument_CHSI	C. Focus Group Participant Recruitment Instrument_CHSI.docx	No	Fillable Printable
Form and Instruction	16ADY	D. Focus Group Interview Guide Instrument_CHSI	D. Focus Group Interview Guide Instrument_CHSI.docx	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 78	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	78	78
Annual IC Time Burden (Hours)	37	37
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
A. Targeted Local Health Departments_CHSI	A. Targeted Local Health Departments_CHSI.docx	04/22/2016
E. Contact Reminder Call_CHSI	E. Contact Reminder Call_CHSI.docx	04/22/2016
F. Focus Group Scheduling Call_CHSI	F. Focus Group Scheduling Call_CHSI.docx	04/22/2016
G. Focus Group Confirmation Email_CHSI	G. Focus Group Confirmation Email_CHSI.docx	04/22/2016
H. Focus Group Confirmation Call_CHSI	H. Focus Group Confirmation Call_CHSI.docx	04/22/2016
SSA CHSI-EVAL	CHSI-EVAL-SSA.docx	04/22/2016
SSB CHSI-EVAL	CHSI-EVAL-SSB.docx	04/22/2016

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