Information Collection

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

IC 190117 under ICR 200907-0915-003 · OMB 0915-0329.

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

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 Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	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.