Information Collection

Local Health Department and th HHE Program Brochure Survey

IC 225028 under ICR 201501-0920-025 · OMB 0920-0940.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

17JJ

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
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 %

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

Documents for IC

table that charts IC Documents
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.