Information Collection

Community Health Workers CHW Survey

IC 260599 under ICR 202306-0920-005 · OMB 0920-1411.

Documents and Forms

Document Name Document Type
Community Health Workers CHW Survey Form and Instruction
CHW Survey Att 5 - CHW Survey English.pdf Form and Instruction
CHW Survey Att 5 - CHW Survey English.pdf Form and Instruction
Att 5a – CHW) Survey Spanish.pdf CHW Survey (Spanish) IC Document
Att 5a – CHW) Survey Spanish.pdf CHW Survey (Spanish) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Community Health Workers CHW Survey	Agency IC Tracking Number:	0920-23AH

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	CHW Survey	Att 5 - CHW Survey English.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 367	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	367	367
Annual IC Time Burden (Hours)	184	184
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CHW Survey (Spanish)	Att 5a â CHW) Survey Spanish.pdf	06/09/2023

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