Information Collection

Application Packets for Real Property for Public Health Purposes

IC 7743 under ICR 202408-0937-001 · OMB 0937-0191.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0937-0191 can be found here:

2024-12-13 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

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

table that charts list of 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

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	Approved	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

table that charts IC Documents
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.