County Health Policy Implementation 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⚠️ Notice: This information collection may be referencing outdated material.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
County Health Policy Implementation Assessment Form
County Health Policy Implementation Assessment - Single- Attachment C Instrument_Web version for single county LHDs.docx Form
County Health Policy Implementation Assessment - Multi-c Attachment D Instrument_Web version for multi-county health districts.docx Form
County Health Policy Implementation Assessment - Word Ve Attachment B Instrument_Word version.docx Form
Additional County Supplement Attachment E CHPIA Additional County Supplement.docx Form
CHPIA-SSA.docx Supporting Statement A IC Document
CHPIA-SSB.docx Supporting Statement B IC Document
CHPIA-SSB.docx Supporting Statement B IC Document
Attachment A List of counties and subjects.xlsx List of Counties and Subjects IC Document
Attachment A List of counties and subjects.xlsx List of Counties and Subjects IC Document
Attachment F Email Notification.docx Email Notification IC Document
Attachment G Email Reminder.docx Email Reminder IC Document
Attachment G Email Reminder.docx Email Reminder IC Document
Attachment H Letter Reminder.docx Letter Reminder IC Document
Attachment H Letter Reminder.docx Letter Reminder IC Document
Attachment I Instructions for Local Health Departments Serving Multiple Counties.docx Instructions for LHD Serving Multiple Counties IC Document

Information Collection (IC) Details

IC Title:	County Health Policy Implementation Assessment	Agency IC Tracking Number:	16AMT

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	County Health Policy Implementation Assessment - Single-County Web Version	Attachment C Instrument_Web version for single county LHDs.docx	Yes	Yes	Fillable Fileable
Form	none	County Health Policy Implementation Assessment - Multi-county - Web Version	Attachment D Instrument_Web version for multi-county health districts.docx	Yes	Yes	Fillable Fileable
Form	none	County Health Policy Implementation Assessment - Word Version	Attachment B Instrument_Word version.docx	Yes	No	Paper Only
Form	none	Additional County Supplement	Attachment E CHPIA Additional County Supplement.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	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	120	120
Annual IC Time Burden (Hours)	47	47
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	CHPIA-SSA.docx	06/06/2016
Supporting Statement B	CHPIA-SSB.docx	06/06/2016
Supporting Statement B	CHPIA-SSB.docx	06/06/2016
List of Counties and Subjects	Attachment A List of counties and subjects.xlsx	06/06/2016
List of Counties and Subjects	Attachment A List of counties and subjects.xlsx	06/06/2016
Email Notification	Attachment F Email Notification.docx	06/06/2016
Email Reminder	Attachment G Email Reminder.docx	06/06/2016
Email Reminder	Attachment G Email Reminder.docx	06/06/2016
Letter Reminder	Attachment H Letter Reminder.docx	06/06/2016
Letter Reminder	Attachment H Letter Reminder.docx	06/06/2016
Instructions for LHD Serving Multiple Counties	Attachment I Instructions for Local Health Departments Serving Multiple Counties.docx	06/06/2016

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