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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.