Information Collection

Web-based Survey

IC 194421 under ICR 201008-0930-007 · OMB 0930-0318.

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.