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Customer Focus Group Screener
Health Hazard Evaluation Program Customer Survey
OMB: 0920-0803
IC ID: 187117
OMB.report
HHS/CDC
OMB 0920-0803
ICR 200811-0920-002
IC 187117
( )
Documents and Forms
Document Name
Document Type
Form no number
Customer Focus Group Screener
Form
no number Focus Group Screener
Attachment D Focus Group Screener.doc
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Customer Focus Group Screener
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
no number
Focus Group Screener
Attachment D Focus Group Screener.doc
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
216
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Approved
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
216
0
216
0
0
0
Annual IC Time Burden (Hours)
54
0
54
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.
