Information Collection

Short CAM Questionnaire

IC 186837 under ICR 200809-0925-003 · OMB 0925-0530.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0530 can be found here:

Documents and Forms

Document Name Document Type
Form Form #1 Short CAM Questionnaire Form and Instruction
Form #1 Short CAM Questionnaire consumer materials survey 7 29 08 (7)[1].doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Short CAM Questionnaire	Agency IC Tracking Number:

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	Form #1	Short CAM Questionnaire	consumer materials survey 7 29 08 (7)[1].doc		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	200	0	0	0	0	0
Annual IC Time Burden (Hours)	20	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	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.