Survey (State, Local, Tribal Governments)

Indian Affairs Public Health Needs Assessment

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.