Information Collection

State Oral Health Program Assessment

IC 233547 under ICR 201711-0920-012 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment A- Instrument- Online Survey Word Version.docx	Other-Word version of the Online Sur
Online Survey (screen captures) Attachment B- Instrument- Online Survey Web Version.docx	Form and Instruction
Telephone Interview Guide for State Oral Health Staff Attachment C- Instrument- Telephone Interview Guide.docx	Form and Instruction
ORAL-SSB.docx Supporting Statement - Part B	IC Document
Attachment D- Online Survey Invitational Email.docx Invitation Email for the Online Survey	IC Document
Attachment E- Online Survey Reminder Email.docx Reminder Email for the Online Survey	IC Document
Attachment F- Telephone Interview Invitation Email.docx Invitation Email for the Telephone Interview	IC Document
Attachment G- Telephone Interview Reminder Email.docx Reminder Email for the Telephone Interview	IC Document
ORAL-SSA.docx Supporting Statement - Part A	IC Document

IC Title:

State Oral Health Program Assessment

Agency IC Tracking Number:

0920-19AV

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Word version of the Online Survey (for reference)			Attachment A- Instrument- Online Survey Word Version.docx	No		Paper Only
Form and Instruction	n/a	Online Survey (screen captures)	Attachment B- Instrument- Online Survey Web Version.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Telephone Interview Guide for State Oral Health Staff	Attachment C- Instrument- Telephone Interview Guide.docx	No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 82 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	31	31
Annual IC Cost Burden (Dollars)	2,077	2,077

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement - Part B	ORAL-SSB.docx	10/16/2018
Invitation Email for the Online Survey	Attachment D- Online Survey Invitational Email.docx	10/16/2018
Reminder Email for the Online Survey	Attachment E- Online Survey Reminder Email.docx	10/16/2018
Invitation Email for the Telephone Interview	Attachment F- Telephone Interview Invitation Email.docx	10/16/2018
Reminder Email for the Telephone Interview	Attachment G- Telephone Interview Reminder Email.docx	10/16/2018
Supporting Statement - Part A	ORAL-SSA.docx	10/23/2018

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