Information Collection

Questionnaire Telephone Script (State & Local Gov't Organizations)

IC 178807 under ICR 200702-0920-005 · OMB 0920-0255.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0255 can be found here:

Documents and Forms

Document Name Document Type
Questionnaire Telephone Script (State & Local Gov't Organizations) Form and Instruction
Appendix D: Questionnaire (Telephone Script) Questionnaire (Telephone Script).doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Questionnaire Telephone Script (State & Local Gov't Organizations)	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	None	Appendix D: Questionnaire (Telephone Script)	Questionnaire (Telephone Script).doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 75	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	21	21
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.