Survey of Private Sector Partners

Evaluation of the Action Plan for the National Public Health Initiative on Diabetes and Womens Health

Documents and Forms

Document Name Document Type
Form 2 Survey of Private Sector Partners Form and Instruction
2 Survey of State-based Diabetes Prevention and Control Pr Attachment D Partner Survey.doc Form and Instruction
Attachment D2 Partner Reminder.doc Attachment D2 Partner Reminder IC Document
Attachment D1 Partner Invitation.doc Attachment D1 Partner Invitation IC Document

Information Collection (IC) Details

IC Title:	Survey of Private Sector Partners	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 and Instruction	2	Survey of State-based Diabetes Prevention and Control Programs	Attachment D Partner Survey.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment D2 Partner Reminder	Attachment D2 Partner Reminder.doc	11/12/2009
Attachment D1 Partner Invitation	Attachment D1 Partner Invitation.doc	11/12/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.