Information Collection

Client-level interview-Physical Health Indicators

IC 196135 under ICR 201506-0930-002 · OMB 0930-0340.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Physical Health In Client-level interview-Physical Health Indicators	Form and Instruction
Physical Health In Physical Health Indicators Attachment 1 Physical Health Indicators 8 12 2014.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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 and Instruction	Physical Health Indicators	Physical Health Indicators	Attachment 1 Physical Health Indicators 8 12 2014.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14,000

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
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-28,000	28,000
Annual IC Time Burden (Hours)	-2,240	2,240
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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