Information Collection

Accredited one year health departments

IC 239112 under ICR 202301-0920-008 · OMB 0920-1295.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Accredited one year health departments	Form
Accredited one year health departments AttachmentG_Survey3-Screenshot.pdf	Form
Accredited one year health departments AttachmentG_Survey3-Screenshot.pdf	Form
AttachmentQ_Survey3-Invitation.docx Survey invitation	IC Document
AttachmentQ_Survey3-Invitation.docx Survey invitation	IC Document
AttachmentV_Survey3-Reminder.docx Survey reminder	IC Document
AttachmentV_Survey3-Reminder.docx Survey reminder	IC Document

IC Title:

Agency IC Tracking Number:

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	Accredited one year health departments	AttachmentG_Survey3-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	AttachmentQ_Survey3-Invitation.docx	12/30/2019
Survey reminder	AttachmentV_Survey3-Reminder.docx	12/30/2019

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