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Bright Futures for Women's Health and Wellness - Distributor Survey
Bright Futures for Women's Health and Wellness
OMB: 0915-0329
IC ID: 190117
OMB.report
HHS/HSA
OMB 0915-0329
ICR 200907-0915-003
IC 190117
( )
Documents and Forms
Document Name
Document Type
Form 002_BFWHWEmWell_Di
Bright Futures for Women's Health and Wellness - Distributor Survey
Form
002_BFWHWEmWell_Di 002_BFWHWEmWell_Dist
BFWHW Distributor Survey Tool.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Bright Futures for Women's Health and Wellness - Distributor 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
002_BFWHWEmWell_Dist
002_BFWHWEmWell_Dist
BFWHW Distributor Survey Tool.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
40
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
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
40
0
40
0
0
0
Annual IC Time Burden (Hours)
10
0
10
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.
