Information Collection

Applicant Health Departments

IC 239110 under ICR 201912-0920-015 · OMB 0920-1295.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1295 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Applicant Health Departments	Form
Survey 1 AttachmentC_Survey1-Screenshot.pdf	Form
AttachmentO_Survey1-Invitation.docx Survey invitation	IC Document
AttachmentT_Survey1-Reminder.docx Survey reminder	IC Document

IC Title:

Applicant Health Departments

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
Form	none	Survey 1	AttachmentC_Survey1-Screenshot.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

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	60	60
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	814	814

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey invitation	AttachmentO_Survey1-Invitation.docx	12/30/2019
Survey reminder	AttachmentT_Survey1-Reminder.docx	12/30/2019

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