Information Collection

Community Health Status Indicators (CHSI) 2015: Awareness, Use, and Benefits Assessment

IC 221208 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.