Community Drinking Water Monitoring Form

Environmental Public Health Tracking Network (Tracking Network)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 0920-1175 Community Drinking Water Monitoring Form Form and Instruction
0920-1175 Community Drinking Water Monitoring Form Att4c_CommunityDW_Form_2020.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Community Drinking Water Monitoring Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1175	Community Drinking Water Monitoring Form	Att4c_CommunityDW_Form_2020.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	30	0	30
Annual IC Time Burden (Hours)	3,000	-600	3,600
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.