Needs Assessment for Developing a Network of LEHPs

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⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

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:

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 %

	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

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.