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

View Information Collection (IC)

SLPHERLT 0920-0879-19TH
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 0920-0879 Web-Based Assessment Attachment C - Web-Based Assessment Word Version_30Jan19.docx NA Yes Yes Fillable Fileable
Form and Instruction 0920-0879 Focus Group Facilitation Guide Attachment E - Focus Group Facilitation Guide Word Version_30Jan19.docx NA No   Fillable Fileable

Health Consumer Health and Safety

 

762 0
   
State, Local, and Tribal Governments
 
   96 %

  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 762 0 762 0 0 0
Annual IC Time Burden (Hours) 283 0 283 0 0 0
Annual IC Cost Burden (Dollars) 12,217 0 12,217 0 0 0

Title Document Date Uploaded
SSA SLPHERLT-SSA final.docx 02/12/2019
SSB SLPHERLT-SSB.docx 02/12/2019
Respondent Universe Attachment A - Respondent Universe_30Jan19.docx 02/12/2019
Sample of Respondents Attachment B - Sample of Respondents_30Jan19.docx 02/12/2019
Web-Based Assessment Web Version Attachment D - Web-Based Assessment Web Version_30Jan19.docx 02/12/2019
PHEP Director Invitation Email Attachment F - Web-Based Assessment PHEP Director Invitation Email Word Version_30Jan19.docx 02/12/2019
Local Invitation Email Attachment G - Web-Based Assessment Local Invitation Email Word Version_30Jan19.docx 02/12/2019
Web One-Page Factsheet Attachment H - Web-Based Assessment One-Page Factsheet_30Jan19.docx 02/12/2019
PHEP Director Reminder Email Attachment I - Web-Based Assessment PHEP Director Reminder Email Word Version_30Jan19.docx 02/12/2019
Local Reminder Email Attachment J - Web-Based Assessment Local Reminder Email Word Version_30Jan19.docx 02/12/2019
Generic Focus Group Invitation Email Attachment K - Generic Focus Group Invitation Email, Word Version_1Feb19.docx 02/12/2019
Focus Group One-Page Factsheet Attachment L - Focus Group One-Page Factsheet_30Jan19.docx 02/12/2019
Focus Group Enrollment and Waiver Form Attachment M - Focus Group Enrollment and Waiver Form_30Jan19.docx 02/12/2019
Focus Group Participation Confirmation Email Attachment N - Focus Group Participation Confirmation Email_30Jan19.docx 02/12/2019
Focus Group Reminder Call Script Attachment O - Focus Group Reminder Call Script, Word Version_30Jan19.docx 02/12/2019
Focus Group Conduct Reminder Email Attachment P - Focus Group Conduct Reminder Email, Word Version_30Jan19.docx 02/12/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.