Information Collection

ATSDR Health Education Activity Tracking (HEAT) Form

IC 226334 under ICR 202004-0923-001 · OMB 0923-0057.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0057 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ATSDR Health Education Activity Tracking (HEAT) Form	Form and Instruction
Att4a HEAT Form_Word 20200325.docx	Other-Word document to display instr
Health Education (screenshots) Att4a HEAT Form_Screenshots 20200325.docx	Form and Instruction

IC Title:

ATSDR Health Education Activity Tracking (HEAT) Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	n/a	Health Education (screenshots)	Att4a HEAT Form_Screenshots 20200325.docx		Yes	Yes	Fillable Fileable
Other-Word document to display instrument content			Att4a HEAT Form_Word 20200325.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 28

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	1,036	111	925
Annual IC Time Burden (Hours)	52	5	47
Annual IC Cost Burden (Dollars)	1,932	1,932	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.