Information Collection

Evaluation Questionnaire

IC 186348 under ICR 200808-0925-004 · OMB 0925-0594.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0594 can be found here:

Documents and Forms

Document Name Document Type
Form 9 Evaluation Questionnaire Form
9 Evaluation Questionnaire Att 9_EvaluationQuestionnaire.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Evaluation Questionnaire	Agency IC Tracking Number:

Is this a Common Form? Yes		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	9	Evaluation Questionnaire	Att 9_EvaluationQuestionnaire.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,036	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,035	1,035
Annual IC Time Burden (Hours)	17	17
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.