Information Collection

N-SUMHSS (both SU and MH)

IC 243269 under ICR 202311-0930-001 · OMB 0930-0386.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form N-SUMHSS Questionn N-SUMHSS (both SU and MH)	Form and Instruction
N-SUMHSS Questionn N-SUMHSS Questionnaire Attachment A. N-SUMHSS Questionnaire final _202308.pdf	Form and Instruction
N-SUMHSS Questionn N-SUMHSS Questionnaire Attachment A. N-SUMHSS Questionnaire final _202308.pdf	Form and Instruction
Attachment A1. N-SUMHSS Questionnaire - Track Changes final _202308.docx N-SUMHSS Questionnaire - Tracked	IC Document
Attachment A1. N-SUMHSS Questionnaire - Track Changes final _202308.docx N-SUMHSS Questionnaire - Tracked	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 and Instruction	N-SUMHSS Questionnaire	N-SUMHSS Questionnaire	Attachment A. N-SUMHSS Questionnaire final _202308.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

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	5,000	0	5,000
Annual IC Time Burden (Hours)	6,400	815	5,585
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
N-SUMHSS Questionnaire - Tracked	Attachment A1. N-SUMHSS Questionnaire - Track Changes final _202308.docx	11/30/2023

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