Information Collection

State Oral Health and Chronic Disease Programs Integration Assessment

IC 234047 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⚠️ Notice: This information collection may be referencing outdated material.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
State Oral Health and Chronic Disease Programs Integration Assessment	Form and Instruction
Telephone Interview Instrument Attachment B- Instrument- Telephone Interview Oral Health and Chronic Disease Program Staff.docx	Form and Instruction
ORALCHRNC-SSA.docx Supporting Statement Part A	IC Document
ORALCHRNC-SSB.docx Supporting Statement Part B	IC Document
Attachment A – Respondent Breakdown - State Oral health and Chronic Disease Programs.docx Respondent Breakdown	IC Document
Attachment C- Telephone Interview Invitation Email Oral Health and Chronic Disease Program Staff.docx Invitation Email for Telephone Interview	IC Document
Attachment D- Telephone Interview Reminder Email Oral Health and Chronic Disease Program Staff.docx Reminder Email for Telephone Interview	IC Document

IC Title:

State Oral Health and Chronic Disease Programs Integration Assessment

Agency IC Tracking Number:

0920-19EF

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	n/a	Telephone Interview Instrument	Attachment B- Instrument- Telephone Interview Oral Health and Chronic Disease Program Staff.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	547	547

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement Part A	ORALCHRNC-SSA.docx	11/15/2018
Supporting Statement Part B	ORALCHRNC-SSB.docx	11/15/2018
Respondent Breakdown	Attachment A â Respondent Breakdown - State Oral health and Chronic Disease Programs.docx	11/15/2018
Invitation Email for Telephone Interview	Attachment C- Telephone Interview Invitation Email Oral Health and Chronic Disease Program Staff.docx	11/15/2018
Reminder Email for Telephone Interview	Attachment D- Telephone Interview Reminder Email Oral Health and Chronic Disease Program Staff.docx	11/15/2018

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