Healthcare and Public Health Sector Site Assessment Risk Analysis (SARA) Tool Pilot Activity Survey Form

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0379 can be found here:

Documents and Forms

Document Name Document Type
0990-0379 HPH Risk Assessment Tools.docx Other-survey
0990-0379 FastTrackDraft Generic Clearance MEMO_HPH .docx Memo IC Document

Information Collection (IC) Details

IC Title:	Healthcare and Public Health Sector Site Assessment Risk Analysis (SARA) Tool Pilot Activity Survey Form	Agency IC Tracking Number:

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-survey			0990-0379 HPH Risk Assessment Tools.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Memo	0990-0379 FastTrackDraft Generic Clearance MEMO_HPH .docx	01/31/2017

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