Information Collection

Surveys -

IC 181321 under ICR 200707-0930-003 · OMB 0930-0287.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Appendix II - Surv Surveys -	Form and Instruction
Appendix II - Surv Appendix II - Surveys/Interviews Attachment II PAIMI Evaluation Plan with Appendices.doc	Form and Instruction
Attachment I - Web survey example.doc Attachment I - Web Survey Example	IC Document

IC Title:

Surveys -

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 and Instruction	Appendix II - Surveys/Interviews	Appendix II - Surveys/Interviews	Attachment II PAIMI Evaluation Plan with Appendices.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 80

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment I - Web Survey Example	Attachment I - Web survey example.doc	07/13/2007

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