Information Collection

CCRF_Georgia

IC 213373 under ICR 201511-0920-002 · OMB 0920-1011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CCRF_Georgia	Form
Case Investigation Appendix 1. CCHF_Case investigation questionnaire.doc	Form
KAP Survey Appendix 2. KAP Survey.docx	Form
Consent Appendix 3. Consent Form.docx	Form
LOI CCHF Investigation.pdf Letter of Invitation	IC Document
2015001_XXX CCHF_Georgia.docx EEI Request	IC Document

IC Title:

CCRF_Georgia

Agency IC Tracking Number:

15AK

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR USC 301 [241] (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	none	Case Investigation	Appendix 1. CCHF_Case investigation questionnaire.doc	No	Paper Only
Form	none	KAP Survey	Appendix 2. KAP Survey.docx	No	Paper Only
Form	none	Consent	Appendix 3. Consent Form.docx	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 830

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	830	830
Annual IC Time Burden (Hours)	303	303
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter of Invitation	LOI CCHF Investigation.pdf	10/03/2014
EEI Request	2015001_XXX CCHF_Georgia.docx	10/03/2014

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