Information Collection

Survey (State, Local, Tribal Governments)

IC 256325 under ICR 202210-1076-002 · OMB 1076-0200.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1076-0200 can be found here:

Documents and Forms

Document Name Document Type
Survey (State, Local, Tribal Governments) Form and Instruction
Indian Affairs Public Health Needs Assessment Survey Public Health And Safety Needs Assessment Survey_Print Form (Instrument).pdf Form and Instruction
Indian Affairs Public Health Needs Assessment Survey Public Health And Safety Needs Assessment Survey_Print Form (Instrument).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey (State, Local, Tribal Governments)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	N/A	Indian Affairs Public Health Needs Assessment Survey	Public Health And Safety Needs Assessment Survey_Print Form (Instrument).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 750	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	750	750
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.