State Synergy Survey

An Assessment of the State Public Health Actions (“1305”) Program

Documents and Forms

Document Name Document Type
State Synergy Survey Form
State Public Health Actions 1305 State Synergy Survey Att 5_Screenshots of State Synergy Survey_5-23-16.docx Form

Information Collection (IC) Details

IC Title:	State Synergy Survey	Agency IC Tracking Number:

Is this a Common Form? No		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
Form	none	State Public Health Actions 1305 State Synergy Survey	Att 5_Screenshots of State Synergy Survey_5-23-16.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 408	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	408	408
Annual IC Time Burden (Hours)	306	306
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.