Information Collection

N-SUMHSS (both SU and MH)

IC 243269 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⚠️ Notice: This information collection may be referencing outdated material.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:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form N-SUMHSS 2021 Ques N-SUMHSS (both SU and 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

IC Title:

N-SUMHSS (both SU and 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	URL	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

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

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	5,000	5,000
Annual IC Time Burden (Hours)	5,585	5,585
Annual IC Cost Burden (Dollars)	0	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.