Information Collection

Surveys -

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.