Information Collection

Health Department Data

IC 7165 under ICR 201508-0920-003 · OMB 0920-0696.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0696 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attach3A EW home page admin.png	Other-Evaluation Web
Attach5 PEB NHME Comprehensive DVS v11-02-2012.pdf Attach5 PEB NHME Comprehensive DVS v11-02-2012	IC Document

IC Title:

Health Department Data

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

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
Other-Evaluation Web			Attach3A EW home page admin.png		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 69

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	-138	138
Annual IC Time Burden (Hours)	-190,026	190,026
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attach5 PEB NHME Comprehensive DVS v11-02-2012	Attach5 PEB NHME Comprehensive DVS v11-02-2012.pdf	01/03/2013

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