Information Collection

Bright Futures for Women's Health and Wellness - Consumer Survey

IC 190116 under ICR 200907-0915-003 · OMB 0915-0329.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 001_BFWHWEmWellCon Bright Futures for Women's Health and Wellness - Consumer Survey	Form
001_BFWHWEmWellCon 001_BFWHWEmWellCon BFWHW Consumer Survey Tool.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form?

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	001_BFWHWEmWellCon	001_BFWHWEmWellCon	BFWHW Consumer Survey Tool.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 563

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	563	563
Annual IC Time Burden (Hours)	141	141
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.