Information Collection

Participants Survey

IC 194189 under ICR 201008-0930-003 · OMB 0930-0288.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0288 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachment 2 - Par Participants Survey	Form and Instruction
Attachment 2 - Par Attachment 2 - Participants Survey Attachment 2-Participants Survey_060110.doc	Form and Instruction
Attachment 2- Part Attachment 2-Participants Survey Attachment 2-Participants Survey_092710.doc	Form and Instruction
Attachment 2 Attachment 2-Participant Form 102810-Final Attachment 2-Participant Form_102810-FINAL.doc	Form and Instruction
Attachment 6-Registration-Confirmation of Participation Email_060110.doc Attachment 6 - Registration-Confirmation	IC Document
Attachment 6-Participants Survey Card.png Attachment 6-Participants Survey Card	IC Document
Attachment 8-Registration-Confirmation of Participation Email_092710.doc Attachment 8-Registration Confirmation of Participation Email 92710	IC Document

IC Title:

Participants 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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Attachment 2 - Participants Survey	Attachment 2 - Participants Survey	Attachment 2-Participants Survey_060110.doc	Yes	Yes	Paper Only
Form and Instruction	Attachment 2- Participants Survey	Attachment 2-Participants Survey	Attachment 2-Participants Survey_092710.doc	Yes	Yes	Paper Only
Form and Instruction	Attachment 2	Attachment 2-Participant Form 102810-Final	Attachment 2-Participant Form_102810-FINAL.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	12,000	12,000
Annual IC Time Burden (Hours)	996	996
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 6 - Registration-Confirmation	Attachment 6-Registration-Confirmation of Participation Email_060110.doc	08/02/2010
Attachment 6-Participants Survey Card	Attachment 6-Participants Survey Card.png	09/29/2010
Attachment 8-Registration Confirmation of Participation Email 92710	Attachment 8-Registration-Confirmation of Participation Email_092710.doc	09/29/2010

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