Information Collection

Needs Assessment for Developing a Network of LEHPs

IC 221270 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⚠️ Notice: This information collection may be referencing outdated material.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
EHCA_D - EHCA Word Instrument.docx	Other-WORD
EHCA_E - EHCA Web Instrument.docx	Other-Screenshots
EHCA_A - Local Health Department Listing.docx Att A _Local Health Department Listin	IC Document
EHCA_B - Authorizing Law.docx Att B__ Authorizing Law	IC Document
EHCA_C - Madison County LHD Example.docx Att C_Madison County LHD Exampl	IC Document
EHCA_F - EHCA Notification Email.docx Att F_EHCA Notification Email	IC Document
EHCA_G - EHCA Reminder Email.docx Att G _EHCA Reminder Email	IC Document
EHCA-SSA.docx EHCA-SSA	IC Document
EHCA-SSB.docx EHCA-SSB	IC Document

IC Title:

Needs Assessment for Developing a Network of LEHPs

Agency IC Tracking Number:

16AGD

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
Other-WORD			EHCA_D - EHCA Word Instrument.docx		Yes	Yes	Fillable Fileable
Other-Screenshots			EHCA_E - EHCA Web Instrument.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

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	500	500
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att A _Local Health Department Listin	EHCA_A - Local Health Department Listing.docx	04/27/2016
Att B__ Authorizing Law	EHCA_B - Authorizing Law.docx	04/27/2016
Att C_Madison County LHD Exampl	EHCA_C - Madison County LHD Example.docx	04/27/2016
Att F_EHCA Notification Email	EHCA_F - EHCA Notification Email.docx	04/27/2016
Att G _EHCA Reminder Email	EHCA_G - EHCA Reminder Email.docx	04/27/2016
EHCA-SSA	EHCA-SSA.docx	04/27/2016
EHCA-SSB	EHCA-SSB.docx	04/27/2016

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