Information Collection

NGC Evaluation Survey

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NGC Evaluation 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 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 %

	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

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.