Information Collection

Health Department Needs Assessment

IC 251349 under ICR 202201-0920-008 · OMB 0920-1377.

Documents and Forms

Document Name Document Type
Form 0920- Health Department Needs Assessment Form and Instruction
0920- Health Departments Needs Assessment Att 3b_Health Departments Needs Assessment.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Department Needs Assessment	Agency IC Tracking Number:	0920-21HU

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	0920-	Health Departments Needs Assessment	Att 3b_Health Departments Needs Assessment.docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 70	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	70	70
Annual IC Time Burden (Hours)	23	23
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.