Information Collection

State Survey

IC 232037 under ICR 201807-0910-004 · OMB 0910-0855.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0855 can be found here:

Documents and Forms

Document Name Document Type
Appendix A - NAFDS Survey.docx Other-Survey
Appendix B NAFDS Survey Email Invitation.docx Email Invitation IC Document
Screenshot Login Page.PNG Log In Page IC Document
Screenshot Disclaimer Security.PNG Disclaimer IC Document
Screenshot Suvey Results.pdf Survey Results IC Document
Instructions.PNG Instructions IC Document
Screenshot Survey.PNG Survey IC Document
Screenshot 2.PNG Screenshot 2 IC Document
Screenshot 2.2.PNG Screenshot 2.2 IC Document
Screenshot 3.PNG Screenshot 3 IC Document
Screenshot 4.PNG Screenshot 4 IC Document
Screenshot Thank you page.PNG Thank you page IC Document
Screenshot 1.docx Screenshot 1 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey			Appendix A - NAFDS Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 49	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	49	49
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Email Invitation	Appendix B NAFDS Survey Email Invitation.docx	07/10/2018
Log In Page	Screenshot Login Page.PNG	07/16/2018
Disclaimer	Screenshot Disclaimer Security.PNG	07/16/2018
Survey Results	Screenshot Suvey Results.pdf	07/16/2018
Instructions	Instructions.PNG	07/16/2018
Survey	Screenshot Survey.PNG	07/16/2018
Screenshot 2	Screenshot 2.PNG	07/16/2018
Screenshot 2.2	Screenshot 2.2.PNG	07/16/2018
Screenshot 3	Screenshot 3.PNG	07/16/2018
Screenshot 4	Screenshot 4.PNG	07/16/2018
Thank you page	Screenshot Thank you page.PNG	07/16/2018
Screenshot 1	Screenshot 1.docx	07/23/2018

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