Information Collection

Community Health Workers CHW Survey

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

0920-23AH

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.