Mashpee Wampanoag Indian Health Service Unit Community Health Assessment

Documents and Forms

Document Name Document Type
Form 0917-Mashpee Mashpee Wampanoag Indian Health Service Unit Community Health Assessment Form and Instruction
0917-Mashpee Mashpee Wampanoag Indian Health Service Unit Community H IHS Mashpee CHA_Survey_STC-FINAL VERSION-Changed Questions 5.18.18.pdf Form and Instruction
Part A Mashpee Wampanoag Indian Health Service Unit Community Health Assessment.docx Mashpee Wampanoag Indian Health Service Unit Community Health Assessment IC Document
Part B- Mashpee Wampanoag Indian Health Service Unit Community Health Assessment.docx Mashpee Wampanoag Indian Health Service Unit Part B IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Mashpee Wampanoag Indian Health Service Unit Community Health Assessment	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 and Instruction	0917-Mashpee	Mashpee Wampanoag Indian Health Service Unit Community Health Assessment	IHS Mashpee CHA_Survey_STC-FINAL VERSION-Changed Questions 5.18.18.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 324	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	324	324
Annual IC Time Burden (Hours)	135	135
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Mashpee Wampanoag Indian Health Service Unit Community Health Assessment	Part A Mashpee Wampanoag Indian Health Service Unit Community Health Assessment.docx	06/07/2018
Mashpee Wampanoag Indian Health Service Unit Part B	Part B- Mashpee Wampanoag Indian Health Service Unit Community Health Assessment.docx	06/07/2018

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