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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.