Information Collection

Stakeholder Survey

IC 195856 under ICR 201012-0930-002 · OMB 0930-0320.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0320 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Privacy Pledge Stakeholder Survey	Form
Privacy Pledge Privacy Pledge 4 Attachment 4_Stakeholder Survey.doc	Form
7 Attachment 7_Stakeholder Survey Consent Form.doc Stakeholder Survey Consent Form	IC Document
10 Attachment 10_StakeholderSurvey_IRBapproval.pdf StakeholderSurvey_IRBapproval	IC Document

IC Title:

Stakeholder 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	Privacy Pledge	Privacy Pledge	4 Attachment 4_Stakeholder Survey.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 648

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	648	648
Annual IC Time Burden (Hours)	181	181
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Stakeholder Survey Consent Form	7 Attachment 7_Stakeholder Survey Consent Form.doc	03/16/2011
StakeholderSurvey_IRBapproval	10 Attachment 10_StakeholderSurvey_IRBapproval.pdf	03/16/2011

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