Application Packets for Real Property for Public Health Purposes

OMB: 0937-0191

IC ID: 7743

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0937-0191 can be found here:

2024-12-13 - No material or nonsubstantive change to a currently approved collection
2024-10-25 - Reinstatement without change of a previously approved collection

Documents and Forms

Document Name Document Type
HHS Off Site Application 4.2018.pdf Other-Application
HHS Off Site Application 4.2018.pdf Other-Application
HHS Public Health Application 12.2020.pdf Other-Application
HHS Public Health Application 12.2020.pdf Other-Application
HHS Title V application 12.2020.pdf Other-Application
HHS Title V application 12.2020.pdf Other-Application
AttachmentA.Act.pdf Attachment A policy IC Document
AttachmentA.Act.pdf Attachment A policy IC Document
AttachmentBMcKinney.pdf Attachment B policy IC Document
AttachmentBMcKinney.pdf Attachment B policy IC Document
AttachmentC.CivilAction.pdf Attachment C policy IC Document
AttachmentC.CivilAction.pdf Attachment C policy IC Document
AttachmentE.Part12.pdf Attachment E policy IC Document
AttachmentE.Part12.pdf Attachment E policy IC Document
AttachmentF.Pt12a.pdf Attachment F policy IC Document
AttachmentF.Pt12a.pdf Attachment F policy IC Document
AttachmentG.CEQ.pdf Attachment G policy IC Document
AttachmentG.CEQ.pdf Attachment G policy IC Document
AttachmentH.FedRegNEPA.pdf Attachment H policy IC Document
AttachmentH.FedRegNEPA.pdf Attachment H policy IC Document
AttachmentJ.Offsiteapp.pdf Attachment J IC Document
AttachmentJ.Offsiteapp.pdf Attachment J IC Document
AttachmentK.hmlsuseapp.pdf Attachment K IC Document
AttachmentK.hmlsuseapp.pdf Attachment K IC Document
AttachmentL.hmlsapp.pdf Attachment L IC Document
AttachmentL.hmlsapp.pdf Attachment L IC Document
AttachmentM.Revisions.pdf Attachment M IC Document
AttachmentM.Revisions.pdf Attachment M IC Document
AttachmentN.7.10.06FedReg.pdf Attachment N IC Document
AttachmentN.7.10.06FedReg.pdf Attachment N IC Document
HHS Public Health Application 5.2019.pdf Attachment I IC Document
HHS Public Health Application 5.2019.pdf Attachment I IC Document
HHS Title V application 6.2019.pdf Attachment K IC Document
HHS Title V application 6.2019.pdf Attachment K IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application Packets for Real Property for Public Health Purposes	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 12-12a 40 CFR 1500-1508 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-Application	HHS Off Site Application 4.2018.pdf	No	Paper Only
Other-Application	HHS Public Health Application 12.2020.pdf	No	Paper Only
Other-Application	HHS Title V application 12.2020.pdf	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	3,000	3,000
Annual IC Cost Burden (Dollars)	1,125	1,125

Documents for IC

Title	Document	Date Uploaded
Attachment A policy	AttachmentA.Act.pdf	12/14/2016
Attachment B policy	AttachmentBMcKinney.pdf	12/14/2016
Attachment C policy	AttachmentC.CivilAction.pdf	12/14/2016
Attachment E policy	AttachmentE.Part12.pdf	12/14/2016
Attachment F policy	AttachmentF.Pt12a.pdf	12/14/2016
Attachment G policy	AttachmentG.CEQ.pdf	12/14/2016
Attachment H policy	AttachmentH.FedRegNEPA.pdf	12/14/2016
Attachment J	AttachmentJ.Offsiteapp.pdf	12/14/2016
Attachment K	AttachmentK.hmlsuseapp.pdf	12/14/2016
Attachment L	AttachmentL.hmlsapp.pdf	12/14/2016
Attachment M	AttachmentM.Revisions.pdf	12/14/2016
Attachment N	AttachmentN.7.10.06FedReg.pdf	12/14/2016
Attachment I	HHS Public Health Application 5.2019.pdf	04/15/2021
Attachment K	HHS Title V application 6.2019.pdf	04/15/2021

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