LHD HAI/AR Strategy Pilot Feedback Form

Pilot Plan for the Interim Local Health Department Strategy for Response, Control, and Prevention of Healthcare Associated Infections (HAI) and Antibiotic Resistance (AR)

Documents and Forms

Document Name Document Type
LHD HAI/AR Strategy Pilot Feedback Form Form and Instruction
Feedback Form Att 3a LHD HAIAR Strategy Pilot FEEDBACK FORM_final 8.30.22.docx Form and Instruction
Feedback Form Att 3a LHD HAIAR Strategy Pilot FEEDBACK FORM_final 8.30.22.docx Form and Instruction

Information Collection (IC) Details

IC Title:	LHD HAI/AR Strategy Pilot Feedback Form	Agency IC Tracking Number:	0920-22GG

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	n/a	Feedback Form	Att 3a LHD HAIAR Strategy Pilot FEEDBACK FORM_final 8.30.22.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	240	240
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.