Information Collection

The Community Tobacco Prevention Assessment and Community COVID-19 Prevention Assessment

IC 252150 under ICR 202201-0917-001 · OMB 0917-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0036 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0917-0036 Community Commercial Tobacco Use Survey The Community Tobacco Prevention Assessment and Community COVID-19 Prevention Assessment	Form and Instruction
Form 0917-0036 Community COVID19 Prevention Assessment The Community Tobacco Prevention Assessment and Community COVID-19 Prevention Assessment	Form and Instruction
0917-0036 Community Commercial Tobacco Use Survey Community Commercial Tobacco Use Survey 051921f sj.docx	Form and Instruction
0917-0036 Community COVID19 Prevention Assessment Community COVID19 Prevention Assessment sjones 071921f.docx	Form and Instruction
Generic Clearance Submission Template - IHS for Tobacco and Covid 19 Assessment Implementation.docx Submission Template	IC Document

IC Title:

The Community Tobacco Prevention Assessment and Community COVID-19 Prevention Assessment

Agency IC Tracking Number:

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	0917-0036				No		Printable Only
Form and Instruction	0917-0036				No		Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	83	83
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Submission Template		03/14/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].