Information Collection

Environmental Public Health Tracking Work Plan Template

IC 222650 under ICR 201807-0920-005 · OMB 0920-1175.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1175 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Environmental Public Health Tracking Work Plan Template	Form and Instruction
Program Management Tool (New Awardees) Form Att5a_ProgramManagmentTool_Form.doc	Form and Instruction
0920-1175 Environmental Public Health Tracking Work Plan Template Attachment5a_REVISEDJul2018.Environmental Public Health Tracking Work Plan Template (clean).xlsx	Form and Instruction

IC Title:

Environmental Public Health Tracking Work Plan Template

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	NA	Program Management Tool (New Awardees) Form	Att5a_ProgramManagmentTool_Form.doc	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1175	Environmental Public Health Tracking Work Plan Template	Attachment5a_REVISEDJul2018.Environmental Public Health Tracking Work Plan Template (clean).xlsx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 26

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	Previously Approved
Annual Number of Responses for this IC	52	-52	104
Annual IC Time Burden (Hours)	1,560	-520	2,080
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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