Information Collection

N-SUMHSS (either SU or MH)

IC 243268 under ICR 202008-0930-002 · OMB 0930-0386.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0386 can be found here:

2023-11-30 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form N-SUMHSS 2021 Ques N-SUMHSS (either SU or MH)	Form and Instruction
N-SUMHSS 2021 Ques N-SUMHSS 2021 Questionnaire Attachment B1_N-SUMHSS 2021 Questionnaire 060320.docx	Form and Instruction
N-SUMHSS 2021 Ques N-SUMHSS 2021 Questionnaire Attachment B1_N-SUMHSS 2021 Questionnaire 060320.docx	Form and Instruction
N-SUMHSS 2021 Web N-SUMHSS 2021 Web Survey Prototype Attachment B3_N-SUMHSS 2021 Web Survey Prototype 072320.docx	Form and Instruction
N-SUMHSS 2021 Web N-SUMHSS 2021 Web Survey Prototype Attachment B3_N-SUMHSS 2021 Web Survey Prototype 072320.docx	Form and Instruction
N-SUMHSS 2021 CATI N-SUMHSS 2021 CATI Questionnaire Attachment B4_N-SUMHSS 2021 CATI Questionnaire 061220.docx	Form and Instruction
N-SUMHSS 2021 CATI N-SUMHSS 2021 CATI Questionnaire Attachment B4_N-SUMHSS 2021 CATI Questionnaire 061220.docx	Form and Instruction
Attachment B5_N-SUMHSS 2021 Advance Letter v051920.docx N-SUMHSS 2021 Advance Letter	IC Document
Attachment B5_N-SUMHSS 2021 Advance Letter v051920.docx N-SUMHSS 2021 Advance Letter	IC Document
Attachment B6_N-SUMHSS 2021 Cover Letter_Web Access Instructions_FAQs_061020.pdf N-SUMHSS 2021 Cover Letter_Web Access Instructions_FAQs	IC Document
Attachment B6_N-SUMHSS 2021 Cover Letter_Web Access Instructions_FAQs_061020.pdf N-SUMHSS 2021 Cover Letter_Web Access Instructions_FAQs	IC Document
Attachment B7_N-SUMHSS 2021 Thank You Reminder Letter v052020.docx N-SUMHSS 2021 Thank You Reminder Letter	IC Document
Attachment B7_N-SUMHSS 2021 Thank You Reminder Letter v052020.docx N-SUMHSS 2021 Thank You Reminder Letter	IC Document
Attachment B10_N-SUMHSS 2021 Completion Thank You Letter v061220.DOCX N-SUMHSS 2021 Completion Thank You Letter	IC Document
Attachment B10_N-SUMHSS 2021 Completion Thank You Letter v061220.DOCX N-SUMHSS 2021 Completion Thank You Letter	IC Document
Attachment B8_N-SUMHSS 2021 Second Mailing Cover Letter v052020.docx N-SUMHSS 2021 Second Mailing Cover Letter	IC Document
Attachment B8_N-SUMHSS 2021 Second Mailing Cover Letter v052020.docx N-SUMHSS 2021 Second Mailing Cover Letter	IC Document
Attachment B9_N-SUMHSS 2021 Third Mailing Cover Letter v061220.DOCX N-SUMHSS 2021 Third Mailing Cover Letter	IC Document
Attachment B9_N-SUMHSS 2021 Third Mailing Cover Letter v061220.DOCX N-SUMHSS 2021 Third Mailing Cover Letter	IC Document
Attachment B12_Prototype of 2021 N-SUMHSS Information Website.docx Prototype of 2021 N-SUMHSS Information Website	IC Document
Attachment B12_Prototype of 2021 N-SUMHSS Information Website.docx Prototype of 2021 N-SUMHSS Information Website	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

N-SUMHSS (either SU or MH)

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	N-SUMHSS 2021 Questionnaire	N-SUMHSS 2021 Questionnaire	Attachment B1_N-SUMHSS 2021 Questionnaire 060320.docx	Yes	Yes	Fillable Fileable
Form and Instruction	N-SUMHSS 2021 Web Survey Prototype	N-SUMHSS 2021 Web Survey Prototype	Attachment B3_N-SUMHSS 2021 Web Survey Prototype 072320.docx	Yes	Yes	Fillable Fileable
Form and Instruction	N-SUMHSS 2021 CATI Questionnaire	N-SUMHSS 2021 CATI Questionnaire	Attachment B4_N-SUMHSS 2021 CATI Questionnaire 061220.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 32,000

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	32,000	32,000
Annual IC Time Burden (Hours)	21,440	21,440
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
N-SUMHSS 2021 Advance Letter	Attachment B5_N-SUMHSS 2021 Advance Letter v051920.docx	08/20/2020
N-SUMHSS 2021 Cover Letter_Web Access Instructions_FAQs	Attachment B6_N-SUMHSS 2021 Cover Letter_Web Access Instructions_FAQs_061020.pdf	08/20/2020
N-SUMHSS 2021 Thank You Reminder Letter	Attachment B7_N-SUMHSS 2021 Thank You Reminder Letter v052020.docx	08/20/2020
N-SUMHSS 2021 Completion Thank You Letter	Attachment B10_N-SUMHSS 2021 Completion Thank You Letter v061220.DOCX	08/20/2020
N-SUMHSS 2021 Second Mailing Cover Letter	Attachment B8_N-SUMHSS 2021 Second Mailing Cover Letter v052020.docx	08/20/2020
N-SUMHSS 2021 Third Mailing Cover Letter	Attachment B9_N-SUMHSS 2021 Third Mailing Cover Letter v061220.DOCX	08/20/2020
Prototype of 2021 N-SUMHSS Information Website	Attachment B12_Prototype of 2021 N-SUMHSS Information Website.docx	08/20/2020

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