Information Collection

STD PCHD Performance Measures (state health departments)

IC 239486 under ICR 201912-0920-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
STD PCHD Performance Measures (state health departments)	Form
Data Collection Tool Att 4_Data Collection Tool.xlsx	Form
Att 4_Data Collection Tool.pdf Home Page for the Data Collection Tool	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	n/a	Data Collection Tool	Att 4_Data Collection Tool.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	1,500	1,500
Annual IC Cost Burden (Dollars)	54,585	54,585

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Home Page for the Data Collection Tool	Att 4_Data Collection Tool.pdf	01/24/2020

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