MUH Operator Baseline Survey

Adoption, Health Impact and Cost of Smoke-Free Multi-Unit Housing Policies

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1004 can be found here:

Documents and Forms

Document Name Document Type
MUH Operator Baseline Survey Form
MUH Operator Baseline Survey Att 6A(e) Baseline Operator Survey_8 30 2012.doc Form
Att 6A-2_MUH Operator Survey Consent MN ME FL.docx Survey Consent - MN, ME, FL IC Document
Att 6A-1_LMUH Operator Survey Consent LA.docx Survey Consent - LA IC Document

Information Collection (IC) Details

IC Title:	MUH Operator Baseline 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	MUH Operator Baseline Survey	Att 6A(e) Baseline Operator Survey_8 30 2012.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 136	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	136	136
Annual IC Time Burden (Hours)	170	170
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Survey Consent - MN, ME, FL	Att 6A-2_MUH Operator Survey Consent MN ME FL.docx	09/24/2012
Survey Consent - LA	Att 6A-1_LMUH Operator Survey Consent LA.docx	09/24/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.