Information Collection

ASP Questionnaire

IC 194862 under ICR 201010-0935-001 · OMB 0935-0172.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #3 ASP Questionnaire	Form and Instruction
Form #3 ASP Questionnaire - intervention sites Attachment D -- ASP questionnaire -- intervention sites.doc	Form and Instruction
Form #4 ASP Questionnaire - control sites Attachment E -- ASP questionnaire -- control sites.doc	Form and Instruction

IC Title:

ASP Questionnaire

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	Form #3	ASP Questionnaire - intervention sites	Attachment D -- ASP questionnaire -- intervention sites.doc		Yes	Yes	Paper Only
Form and Instruction	Form #4	ASP Questionnaire - control sites	Attachment E -- ASP questionnaire -- control sites.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	1,540	1,540
Annual IC Time Burden (Hours)	180	180
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.