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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.