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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.