Information Collection

Application Packets for Real Property for Public Health Purposes

IC 7743 under ICR 201906-0937-003 · OMB 0937-0191.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0937-0191 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0937-0191FINAL HHS Off Site Application 8.31.17.pdf	Other-application
0937-0191FINAL HHS Public Health Application 8.31.17.pdf	Other-application
0937-0191Final HHS Title V application 8.31.17.pdf	Other-application
AttachmentA.Act.pdf Attachment A policy	IC Document
AttachmentBMcKinney.pdf Attachment B policy	IC Document
AttachmentC.CivilAction.pdf Attachment C policy	IC Document
AttachmentE.Part12.pdf Attachment E policy	IC Document
AttachmentF.Pt12a.pdf Attachment F policy	IC Document
AttachmentG.CEQ.pdf Attachment G policy	IC Document
AttachmentH.FedRegNEPA.pdf Attachment H policy	IC Document
AttachmentI.PubHlthapp.pdf Attachment I	IC Document
AttachmentJ.Offsiteapp.pdf Attachment J	IC Document
AttachmentK.hmlsuseapp.pdf Attachment K	IC Document
AttachmentL.hmlsapp.pdf Attachment L	IC Document
AttachmentM.Revisions.pdf Attachment M	IC Document
AttachmentN.7.10.06FedReg.pdf Attachment N	IC Document

IC Title:

Application Packets for Real Property for Public Health Purposes

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 12-12a 40 CFR 1500-1508 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-application	0937-0191FINAL HHS Off Site Application 8.31.17.pdf	Yes	Yes	Fillable Fileable
Other-application	0937-0191FINAL HHS Public Health Application 8.31.17.pdf	Yes	Yes	Fillable Fileable
Other-application	0937-0191Final HHS Title V application 8.31.17.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

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	Previously Approved
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	3,000	3,000
Annual IC Cost Burden (Dollars)	1,125	1,125

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment A policy	AttachmentA.Act.pdf	12/14/2016
Attachment B policy	AttachmentBMcKinney.pdf	12/14/2016
Attachment C policy	AttachmentC.CivilAction.pdf	12/14/2016
Attachment E policy	AttachmentE.Part12.pdf	12/14/2016
Attachment F policy	AttachmentF.Pt12a.pdf	12/14/2016
Attachment G policy	AttachmentG.CEQ.pdf	12/14/2016
Attachment H policy	AttachmentH.FedRegNEPA.pdf	12/14/2016
Attachment I	AttachmentI.PubHlthapp.pdf	12/14/2016
Attachment J	AttachmentJ.Offsiteapp.pdf	12/14/2016
Attachment K	AttachmentK.hmlsuseapp.pdf	12/14/2016
Attachment L	AttachmentL.hmlsapp.pdf	12/14/2016
Attachment M	AttachmentM.Revisions.pdf	12/14/2016
Attachment N	AttachmentN.7.10.06FedReg.pdf	12/14/2016

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