Information Collection

HIC General Survey

IC 189721 under ICR 200906-0925-005 · OMB 0925-0603.

Documents and Forms

Document Name Document Type
Form 1 HIC General Survey Form and Instruction
1 General Survey HIC General Survey Attachment A_052009.docx Form and Instruction
HIC General Survey Attachment B_052009.docx HIC General Survey Attachment B_052009 IC Document
HIC General Survey Attachment C_052009.docx HIC General Survey Attachment C_052009 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HIC General Survey	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	1	General Survey	HIC General Survey Attachment A_052009.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,450	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	809	809
Annual IC Time Burden (Hours)	162	162
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
HIC General Survey Attachment B_052009	HIC General Survey Attachment B_052009.docx	05/22/2009
HIC General Survey Attachment C_052009	HIC General Survey Attachment C_052009.docx	05/22/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.