Information Collection

CQM Health Department Interview

IC 241424 under ICR 202110-0920-012 · OMB 0920-1311.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CQM Health Department Interview	Form and Instruction
CQM State Health Department Interview Guide Att 4a. CQM State HD Interview Guide_rev.docx	Form and Instruction
CQM State Health Department Interview Guide Att 4a. CQM State HD Interview Guide_rev.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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/a	CQM State Health Department Interview Guide	Att 4a. CQM State HD Interview Guide_rev.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 17

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	17	17
Annual IC Time Burden (Hours)	26	26
Annual IC Cost Burden (Dollars)	1,122	1,122

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.