Information Collection

Mashpee Wampanoag Indian Health Service Unit Community Health Assessment

IC 231678 under ICR 201707-0917-001 · OMB 0917-0039.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0917-Mashpee Mashpee Wampanoag Indian Health Service Unit Community Health Assessment	Form and Instruction
0917-Mashpee Mashpee Wampanoag Indian Health Service Unit Community H IHS Mashpee CHA_Survey_STC-FINAL VERSION-Changed Questions 5.18.18.pdf	Form and Instruction
Part A Mashpee Wampanoag Indian Health Service Unit Community Health Assessment.docx Mashpee Wampanoag Indian Health Service Unit Community Health Assessment	IC Document
Part B- Mashpee Wampanoag Indian Health Service Unit Community Health Assessment.docx Mashpee Wampanoag Indian Health Service Unit Part B	IC Document

IC Title:

Agency IC Tracking Number:

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
Form and Instruction	0917-Mashpee	Mashpee Wampanoag Indian Health Service Unit Community Health Assessment	IHS Mashpee CHA_Survey_STC-FINAL VERSION-Changed Questions 5.18.18.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 324

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	324	324
Annual IC Time Burden (Hours)	135	135
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Mashpee Wampanoag Indian Health Service Unit Community Health Assessment	Part A Mashpee Wampanoag Indian Health Service Unit Community Health Assessment.docx	06/07/2018
Mashpee Wampanoag Indian Health Service Unit Part B	Part B- Mashpee Wampanoag Indian Health Service Unit Community Health Assessment.docx	06/07/2018

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