Information Collection

County Health Policy Implementation Assessment

IC 221796 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⚠️ Notice: This information collection may be referencing outdated material.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
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

IC Title:

County Health Policy Implementation Assessment

Agency IC Tracking Number:

16AMT

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?	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 %

table that charts list of burden
	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

table that charts IC Documents
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.