Information Collection

Participant Feedback Form

IC 195850 under ICR 201012-0930-001 · OMB 0930-0195.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0195 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
PFF Instructions.pdf	Instruction
Participant Feedba Participant Feedback Form March 2011 Participant Overall Fdbk Form 0402_001.pdf	Form

IC Title:

Participant Feedback Form

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
Instruction			PFF Instructions.pdf		Yes	Yes	Paper Only
Form	Participant Feedback Form	Participant Feedback Form	March 2011 Participant Overall Fdbk Form 0402_001.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

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	5,000	5,000
Annual IC Time Burden (Hours)	835	835
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.