Information Collection

SECOST Survey (Mail)

IC 179149 under ICR 200703-0920-008 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SECOST Survey (Mail)	Form
SECOST Survey Attachment 9 ASC and HOPD Survey Instruments.doc	Form
Attachment 11 Script for First and Second Reminder Telephone Calls.doc Telephone Reminder Scripts	IC Document
Attachment 8 Survey Cover Letters.doc Survey Cover Letters	IC Document
Attachment 10 Survey Reminder Postcards.doc Survey Reminder Postcards	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	None	SECOST Survey	Attachment 9 ASC and HOPD Survey Instruments.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,725

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,725	1,725
Annual IC Time Burden (Hours)	1,725	1,725
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Telephone Reminder Scripts	Attachment 11 Script for First and Second Reminder Telephone Calls.doc
Survey Cover Letters	Attachment 8 Survey Cover Letters.doc
Survey Reminder Postcards	Attachment 10 Survey Reminder Postcards.doc

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