Information Collection

NGC Evaluation Survey

IC 195598 under ICR 201012-0935-001 · OMB 0935-0174.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 NGC Evaluation Survey	Form and Instruction
Form #1 NGC Evaluation Survey Attachment B - NGC Evaluation Survey.docx www.surveymonkey.com/s/ahrqsurvey	Form and Instruction
Attachment C - Email Announcement.doc Attachment C - Email Announcement	IC Document

IC Title:

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 #1	NGC Evaluation Survey	Attachment B - NGC Evaluation Survey.docx	https://www.surveymonkey.com/s/ahrqsurvey	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40,220

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	40,220	40,220
Annual IC Time Burden (Hours)	5,363	5,363
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment C - Email Announcement	Attachment C - Email Announcement.doc	11/23/2010

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