Web-based Survey

Multiplier Surveys

Documents and Forms

Document Name Document Type
Form Web-based Survey Web-based Survey Form and Instruction
Web-based Survey Web-based Survey Attachment B.docx Form and Instruction
Web-based Survey Web-based Survey Attachment_B_Final.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Web-based 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
Form and Instruction	Web-based Survey	Web-based Survey	Attachment B.docx		Yes	Yes	Paper Only
Form and Instruction	Web-based Survey	Web-based Survey	Attachment_B_Final.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

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

Affected Public: State, Local, and Tribal Governments

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)	75	75
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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