Information Collection

New Facilities 2017-19

IC 202152 under ICR 201612-0930-001 · OMB 0930-0119.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0119 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Locator Survey Que New Facilities 2017-19	Form and Instruction
Locator Survey Que Locator Survey Questionnaire Attachment A.1 2017 N-MHSS Locator Survey Questionnaire_120616.pdf	Form and Instruction

IC Title:

New Facilities 2017-19

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Locator Survey Questionnaire	Locator Survey Questionnaire	Attachment A.1 2017 N-MHSS Locator Survey Questionnaire_120616.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,700

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
	Approved	Previously Approved
Annual Number of Responses for this IC	1,700	1,700
Annual IC Time Burden (Hours)	714	714
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.