Application Packets for Real Property for Public Health Purposes

Documents and Forms

Document Name Document Type
HHS Off Site Application 4.2018.pdf Other-Application
HHS Public Health Application 12.2020.pdf Other-Application
HHS Title V application 12.2020.pdf Other-Application
AttachmentA.Act.pdf Attachment A policy IC Document
AttachmentBMcKinney.pdf Attachment B policy IC Document
AttachmentC.CivilAction.pdf Attachment C policy IC Document
AttachmentE.Part12.pdf Attachment E policy IC Document
AttachmentF.Pt12a.pdf Attachment F policy IC Document
AttachmentG.CEQ.pdf Attachment G policy IC Document
AttachmentH.FedRegNEPA.pdf Attachment H policy IC Document
AttachmentJ.Offsiteapp.pdf Attachment J IC Document
AttachmentK.hmlsuseapp.pdf Attachment K IC Document
AttachmentL.hmlsapp.pdf Attachment L IC Document
AttachmentM.Revisions.pdf Attachment M IC Document
AttachmentN.7.10.06FedReg.pdf Attachment N IC Document
HHS Public Health Application 5.2019.pdf Attachment I IC Document
HHS Title V application 6.2019.pdf Attachment K IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application Packets for Real Property for Public Health Purposes	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 12-12a 40 CFR 1500-1508 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-Application	HHS Off Site Application 4.2018.pdf	No	Paper Only
Other-Application	HHS Public Health Application 12.2020.pdf	No	Paper Only
Other-Application	HHS Title V application 12.2020.pdf	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	10	-5	15
Annual IC Time Burden (Hours)	2,000	-1,000	3,000
Annual IC Cost Burden (Dollars)	2,500	1,375	1,125

Documents for IC

Title	Document	Date Uploaded
Attachment A policy	AttachmentA.Act.pdf	12/14/2016
Attachment B policy	AttachmentBMcKinney.pdf	12/14/2016
Attachment C policy	AttachmentC.CivilAction.pdf	12/14/2016
Attachment E policy	AttachmentE.Part12.pdf	12/14/2016
Attachment F policy	AttachmentF.Pt12a.pdf	12/14/2016
Attachment G policy	AttachmentG.CEQ.pdf	12/14/2016
Attachment H policy	AttachmentH.FedRegNEPA.pdf	12/14/2016
Attachment J	AttachmentJ.Offsiteapp.pdf	12/14/2016
Attachment K	AttachmentK.hmlsuseapp.pdf	12/14/2016
Attachment L	AttachmentL.hmlsapp.pdf	12/14/2016
Attachment M	AttachmentM.Revisions.pdf	12/14/2016
Attachment N	AttachmentN.7.10.06FedReg.pdf	12/14/2016
Attachment I	HHS Public Health Application 5.2019.pdf	04/15/2021
Attachment K	HHS Title V application 6.2019.pdf	04/15/2021

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