Information Collection

Survey (Individuals)

IC 256326 under ICR 202505-1076-001 · OMB 1076-0200.

Documents and Forms

Document Name Document Type
Survey (Individuals) 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 (Individuals)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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: 250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	42	42
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.