Information Collection

HIC General Survey

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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.