Site Assessment Form for Street/Outreach Workers

Homeless Service Providers’ Knowledge, Attitudes, and Practices Regarding Body Lice, Fleas and Associated Diseases

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1372 can be found here:

Documents and Forms

Document Name Document Type
Site Assessment Form for Street/Outreach Workers Form and Instruction
Site Assessment Form - Street/Outreach Workers Att_7_Site_Assessment_Outreach.docx Form and Instruction
Site Assessment Form - Street/Outreach Workers Att_7_Site_Assessment_Outreach.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Site Assessment Form for Street/Outreach Workers	Agency IC Tracking Number:

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	NA	Site Assessment Form - Street/Outreach Workers	Att_7_Site_Assessment_Outreach.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	10	10
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.