Local Health Department and th HHE Program Brochure Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NIOSH)

Documents and Forms

Document Name Document Type
Local Health Department and th HHE Program Brochure Survey Form
Local HD Survey Local Health Department Survey Screenshot.pdf Form
Local HD Survey Local Health Department Survey FY2017.docx Form
OMB Request for Approval LHD HHE 2016-12-22.docx Request for Approval IC Document

Information Collection (IC) Details

IC Title:	Local Health Department and th HHE Program Brochure Survey	Agency IC Tracking Number:	17JJ

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
Form	none	Local HD Survey	Local Health Department Survey Screenshot.pdf		Yes	Yes	Fillable Fileable
Form	none	Local HD Survey	Local Health Department Survey FY2017.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

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)	83	83
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval	OMB Request for Approval LHD HHE 2016-12-22.docx	01/04/2017

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