Information Collection

511 LBI ACSI Questionnaire FINAL.docx - 515 HRSA BPHC Grantee Survey 7-16-12.docx

IC 203404 under ICR 200908-1090-001 · OMB 1090-0007.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1090-0007 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 511 511 LBI ACSI Questionnaire FINAL.docx - 515 HRSA BPHC Grantee Survey 7-16-12.docx	Form and Instruction
511 2012 511 LBI ACSI Questionnaire FINAL.docx 2012 511 LBI ACSI Questionnaire FINAL.docx	Form and Instruction
512 2012 512 SCSE ACSI Questionnaire FINAL.docx 2012 512 SBSE ACSI Questionnaire FINAL.docx	Form and Instruction
513 2012 513 WI ASCI Questionnaire FINAL.doc 2012 513 WI ACSI Questionnaire FINAL.doc	Form and Instruction
514 2012 514 Customer Contact Center Survey E-Verify.docx 2012 514 Customer Contact Center Survey E-Verify.docx	Form and Instruction
515 2012 515 HRSA BPHC Grantee Survey 7-16-12.docx 2012 515 HRSA BPHC Grantee Survey 7-16-12.docx	Form and Instruction

IC Title:

511 LBI ACSI Questionnaire FINAL.docx - 515 HRSA BPHC Grantee Survey 7-16-12.docx

Agency IC Tracking Number:

511 - 515

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	511	2012 511 LBI ACSI Questionnaire FINAL.docx	2012 511 LBI ACSI Questionnaire FINAL.docx	No		Printable Only
Form and Instruction	512	2012 512 SCSE ACSI Questionnaire FINAL.docx	2012 512 SBSE ACSI Questionnaire FINAL.docx	No		Printable Only
Form and Instruction	513	2012 513 WI ASCI Questionnaire FINAL.doc	2012 513 WI ACSI Questionnaire FINAL.doc	No		Printable Only
Form and Instruction	514	2012 514 Customer Contact Center Survey E-Verify.docx	2012 514 Customer Contact Center Survey E-Verify.docx	Yes	Yes	Fillable Fileable
Form and Instruction	515	2012 515 HRSA BPHC Grantee Survey 7-16-12.docx	2012 515 HRSA BPHC Grantee Survey 7-16-12.docx	Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,250

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 40 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,250	1,250
Annual IC Time Burden (Hours)	208	208
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.