Information Collection

OMH Disparity Impact Statement

IC 272887 under ICR 202412-0937-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix F Draft Disparity Impact Statement Template consolidated_03.11.24_PRAv2.docx	Other-Survey
Appendix F Draft Disparity Impact Statement Template consolidated_03.11.24_PRAv2.docx	Other-Survey

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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
Other-Survey			Appendix F Draft Disparity Impact Statement Template consolidated_03.11.24_PRAv2.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 125

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	125	125
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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