Information Collection

Client Survey

IC 194041 under ICR 201008-0930-001 · OMB 0930-0317.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0317 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachments 1a and Client Survey	Form and Instruction
Attachments 1a and Attachments 1a and 1b - Instruments Attachments 1a and 1b.pdf	Form and Instruction
Attachments 2a, 2b, 2c, and 2d.pdf Attachments 2a, 2b, 2c, and 2d - Others	IC Document

IC Title:

Client Survey

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
Form and Instruction	Attachments 1a and 1b - Instruments	Attachments 1a and 1b - Instruments	Attachments 1a and 1b.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,600

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,480	4,480
Annual IC Time Burden (Hours)	1,882	1,882
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachments 2a, 2b, 2c, and 2d - Others	Attachments 2a, 2b, 2c, and 2d.pdf	08/02/2010

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