Information Collection

Facilities Universe in 2017 and 2019

IC 7528 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⚠️ Notice: This information collection may be referencing outdated material.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 Facilities Universe in 2017 and 2019	Form and Instruction
Locator Survey Que Locator Survey Questionnaire Attachment A.1 2017 N-MHSS Locator Survey Questionnaire_120616.pdf	Form and Instruction
Attachment A.3 BHSIS screenshots for OMB_2017_Locator.pdf Web Screens	IC Document
Attachment A.5 N-MHSS CATI questionnaire.pdf CATI Questionnaire	IC Document
2017 NMHSS Letters.pdf Letters	IC Document
2017 NMHSS Other.pdf Other	IC Document

IC Title:

Facilities Universe in 2017 and 2019

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: 17,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	17,000	0	17,000
Annual IC Time Burden (Hours)	4,760	-7,990	12,750
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Web Screens	Attachment A.3 BHSIS screenshots for OMB_2017_Locator.pdf	12/08/2016
CATI Questionnaire	Attachment A.5 N-MHSS CATI questionnaire.pdf	12/08/2016
Letters	2017 NMHSS Letters.pdf	12/08/2016
Other	2017 NMHSS Other.pdf	12/08/2016

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