Information Collection

LHD HAI/AR Strategy Pilot Survey Template

IC 256307 under ICR 202210-0920-003 · OMB 0920-1394.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
LHD HAI/AR Strategy Pilot Survey Template	Form and Instruction
Pilot Survey Template Att 3c LHD HAIAR Strategy Pilot SURVEY_final 8.30.22_9.29.22.docx	Form and Instruction
Pilot Survey Template Att 3c LHD HAIAR Strategy Pilot SURVEY_final 8.30.22_9.29.22.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-22GG

Is this a Common Form? No

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	n/a	Pilot Survey Template	Att 3c LHD HAIAR Strategy Pilot SURVEY_final 8.30.22_9.29.22.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	0	0

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.