Information Collection

Respondents completing paper survey

IC 192720 under ICR 201004-0920-012 · OMB 0920-0862.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix B Questionnaire.doc	Instruction
Appendix D Cover Letter .doc Appendix D Cover letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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
Instruction			Appendix B Questionnaire.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 144

Number of Respondents for Small Entity: 144

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	144	144
Annual IC Time Burden (Hours)	72	72
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix D Cover letter	Appendix D Cover Letter .doc	04/05/2010

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