Information Collection

Flood-Related Community Assessment for Public Health Emergency Response (CASPER) – WV, 2016

IC 222058 under ICR 201609-0920-010 · OMB 0920-1036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1036 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Flood-Related Community Assessment for Public Health Emergency Response (CASPER) – WV, 2016	Form and Instruction
WV Flood 2016 CASPER Questionnaire Flood CASPER Questions_clean.docx	Form and Instruction
WV Flood 2016 CASPER Referral Form Referral Form_WV_Flood_clean.docx	Form and Instruction
LOI_WVflood_CASPER_2016.pdf Letter of Invitation - West Virginia	IC Document
AttachH_Burden Memo.docx Burden Request Memo	IC Document
Signed OS RDF Undetermined Health Effects Among Persons Affected by Flooding_WV 2016.pdf Research Determination	IC Document
G RqstAprvl 12052014 Clean_WV_final.docx CASPER GenIC - Request for Approval	IC Document

IC Title:

Flood-Related Community Assessment for Public Health Emergency Response (CASPER) â WV, 2016

Agency IC Tracking Number:

0920-1036

IC Status: Unchanged

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	NA	WV Flood 2016 CASPER Questionnaire	Flood CASPER Questions_clean.docx	NA	No		Paper Only
Form and Instruction	NA	WV Flood 2016 CASPER Referral Form	Referral Form_WV_Flood_clean.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 215

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	215	215
Annual IC Time Burden (Hours)	105	105
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter of Invitation - West Virginia	LOI_WVflood_CASPER_2016.pdf	07/21/2016
Burden Request Memo	AttachH_Burden Memo.docx	07/21/2016
Research Determination	Signed OS RDF Undetermined Health Effects Among Persons Affected by Flooding_WV 2016.pdf	07/21/2016
CASPER GenIC - Request for Approval	G RqstAprvl 12052014 Clean_WV_final.docx	07/21/2016

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