Information Collection

Customer Satisfaction Surveys: Fast Track Recall Survey, OMBudsman Survey, State Partner Survey, Hotline Survey, Web Site, and Clearinghouse Survey

IC 29182 under ICR 200712-3041-001 · OMB 3041-0128.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
OMB0128.pdf	Other-null

IC Title:

Customer Satisfaction Surveys: Fast Track Recall Survey, Ombudsman Survey, State Partner Survey, Hotline Survey, Web Site, and Clearinghouse Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Other-null			OMB0128.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 684

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 83 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	684	-61	745
Annual IC Time Burden (Hours)	65	15	50
Annual IC Cost Burden (Dollars)	1,821	1,821	0

Documents for IC

table that charts IC Documents
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.