Information Collection

Survey (State, Local, Tribal Governments)

IC 256325 under ICR 202210-1076-002 · OMB 1076-0200.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1076-0200 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Survey (State, Local, Tribal Governments)	Form and Instruction
Indian Affairs Public Health Needs Assessment Survey Public Health And Safety Needs Assessment Survey_Print Form (Instrument).pdf	Form and Instruction
Indian Affairs Public Health Needs Assessment Survey Public Health And Safety Needs Assessment Survey_Print Form (Instrument).pdf	Form and Instruction

IC Title:

Survey (State, Local, Tribal Governments)

Agency IC Tracking Number:

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	Indian Affairs Public Health Needs Assessment Survey	Public Health And Safety Needs Assessment Survey_Print Form (Instrument).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 750

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	750	750
Annual IC Time Burden (Hours)	125	125
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.