Information Collection

Applicant Health Departments

IC 239110 under ICR 202301-0920-008 · OMB 0920-1295.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Applicant Health Departments	Form
Survey 1 AttachmentC_Survey1-Screenshot.pdf	Form
Survey 1 AttachmentC_Survey1-Screenshot.pdf	Form
Attachment P_Survey1_Applicant Survey Invitation Email.docx Survey invitation	IC Document
Attachment P_Survey1_Applicant Survey Invitation Email.docx Survey invitation	IC Document
AttachmentT_Survey1-Reminder.docx Survey reminder	IC Document
AttachmentT_Survey1-Reminder.docx Survey reminder	IC Document

IC Title:

Agency IC Tracking Number:

0920-1295

Is this a Common Form? No

IC Status: Modified

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	none	Survey 1	AttachmentC_Survey1-Screenshot.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	60	0	60
Annual IC Time Burden (Hours)	20	0	20
Annual IC Cost Burden (Dollars)	0	-814	814

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey invitation	Attachment P_Survey1_Applicant Survey Invitation Email.docx	01/17/2023
Survey reminder	AttachmentT_Survey1-Reminder.docx	12/30/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.