Eligible Household (Completes Survey)

Attitudes toward Electronic Health Information Exchange and Associated Privacy and Security Aspects

Documents and Forms

Document Name Document Type
AttachmentD_Questionnaire_FinalRev_070110_FINAL.doc Other-questionaire
0990-attitudestowardelectronic attachment_A_Sample Search Terms.doc 0990-attitudestowardelectronic attachment_A_Sample Search Terms IC Document

Information Collection (IC) Details

IC Title:	Eligible Household (Completes 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
Other-questionaire			AttachmentD_Questionnaire_FinalRev_070110_FINAL.doc		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,570	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	2,570	2,570
Annual IC Time Burden (Hours)	857	857
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
0990-attitudestowardelectronic attachment_A_Sample Search Terms	0990-attitudestowardelectronic attachment_A_Sample Search Terms.doc	03/22/2010

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