Information Collection

State Survey

IC 194214 under ICR 202109-0930-001 · OMB 0930-0316.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0316 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0930-0316 State Su State Survey	Form and Instruction
0930-0316 State Su 0930-0316 State Survey Attachment-2-OMB-0930-0316-State Survey-FIN.docx	Form and Instruction
0930-0316 State Su 0930-0316 State Survey Attachment-2-OMB-0930-0316-State Survey-FIN.docx	Form and Instruction

IC Title:

State Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	0930-0316 State Survey	0930-0316 State Survey	Attachment-2-OMB-0930-0316-State Survey-FIN.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

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	Previously Approved
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	903	903
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.