View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

County Health Policy Implementation Assessment 16AMT
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form none County Health Policy Implementation Assessment - Single-County Web Version Attachment C Instrument_Web version for single county LHDs.docx Yes Yes Fillable Fileable
Form none County Health Policy Implementation Assessment - Multi-county - Web Version Attachment D Instrument_Web version for multi-county health districts.docx Yes Yes Fillable Fileable
Form none County Health Policy Implementation Assessment - Word Version Attachment B Instrument_Word version.docx Yes No Paper Only
Form none Additional County Supplement Attachment E CHPIA Additional County Supplement.docx Yes Yes Fillable Fileable

Health Public Health Monitoring

 

120 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 120 0 120 0 0 0
Annual IC Time Burden (Hours) 47 0 47 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Supporting Statement A CHPIA-SSA.docx 06/06/2016
Supporting Statement B CHPIA-SSB.docx 06/06/2016
Supporting Statement B CHPIA-SSB.docx 06/06/2016
List of Counties and Subjects Attachment A List of counties and subjects.xlsx 06/06/2016
List of Counties and Subjects Attachment A List of counties and subjects.xlsx 06/06/2016
Email Notification Attachment F Email Notification.docx 06/06/2016
Email Reminder Attachment G Email Reminder.docx 06/06/2016
Email Reminder Attachment G Email Reminder.docx 06/06/2016
Letter Reminder Attachment H Letter Reminder.docx 06/06/2016
Letter Reminder Attachment H Letter Reminder.docx 06/06/2016
Instructions for LHD Serving Multiple Counties Attachment I Instructions for Local Health Departments Serving Multiple Counties.docx 06/06/2016
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.