Information Collection

Att H1_Data Collection Checklist

IC 225827 under ICR 201702-0920-016 · OMB 0920-1205.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1205 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att H1_Data Collection Checklist for the NYTS Pilot (Revised 1.12.2017) v2 (OSH).docx	Other-WORD
Att H2_Letter to Teachers in Participating Schools.docx Att H2_Letters to Teachers	IC Document

IC Title:

Att H1_Data Collection Checklist

Agency IC Tracking Number:

16AWN

Is this a Common Form? No

IC Status: New

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
Other-WORD			Att H1_Data Collection Checklist for the NYTS Pilot (Revised 1.12.2017) v2 (OSH).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 292

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	292	292
Annual IC Time Burden (Hours)	73	73
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att H2_Letters to Teachers	Att H2_Letter to Teachers in Participating Schools.docx	03/01/2017

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