Information Collection

State Synergy Survey

IC 222004 under ICR 201606-0920-013 · OMB 0920-1152.

Documents and Forms

Document Name Document Type
State Synergy Survey Form
State Public Health Actions 1305 State Synergy Survey Att 5_Screenshots of State Synergy Survey_5-23-16.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State Synergy Survey	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	none	State Public Health Actions 1305 State Synergy Survey	Att 5_Screenshots of State Synergy Survey_5-23-16.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 408	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	408	408
Annual IC Time Burden (Hours)	306	306
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.