OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

414 ePSS, 415 FCIC 11Feb2011, 416 FCIC Pueblo 11Feb2011, 417 Howto.gov 3.7.2011 , 418 NLM Clinical Trials, 419 CMS Palmetto GBA J11 MAC, 420 Recreation.gov 2-4-2011 to 3-25-11, 421 DHHS-PSC , 422 DOT

IC 197067 under ICR 201101-1090-002 · OMB 1090-0008.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 414 ePSS Questionn
414 ePSS Questionnaire Wave 1 Revised 414 ePSS, 415 FCIC 11Feb2011, 416 FCIC Pueblo 11Feb2011, 417 Howto.gov 3.7.2011 , 418 NLM Clinical Trials, 419 CMS Palmetto GBA J11 MAC, 420 Recreation.gov 2-4-2011 to 3-25-11, 421 DHHS-PSC , 422 DOT		 Form
Form 415 FCIC Consumer
415 FCIC Consumer Action CQ revisions_11Feb2011 414 ePSS, 415 FCIC 11Feb2011, 416 FCIC Pueblo 11Feb2011, 417 Howto.gov 3.7.2011 , 418 NLM Clinical Trials, 419 CMS Palmetto GBA J11 MAC, 420 Recreation.gov 2-4-2011 to 3-25-11, 421 DHHS-PSC , 422 DOT		 Form
Form 416 FCIC Pueblo Su
416 FCIC Pueblo Survey revisions_11Feb2011 414 ePSS, 415 FCIC 11Feb2011, 416 FCIC Pueblo 11Feb2011, 417 Howto.gov 3.7.2011 , 418 NLM Clinical Trials, 419 CMS Palmetto GBA J11 MAC, 420 Recreation.gov 2-4-2011 to 3-25-11, 421 DHHS-PSC , 422 DOT		 Form
Form 417 Howto.gov Surv
417 Howto.gov Survey 3.7.2011 - current 414 ePSS, 415 FCIC 11Feb2011, 416 FCIC Pueblo 11Feb2011, 417 Howto.gov 3.7.2011 , 418 NLM Clinical Trials, 419 CMS Palmetto GBA J11 MAC, 420 Recreation.gov 2-4-2011 to 3-25-11, 421 DHHS-PSC , 422 DOT		 Form
Form 418 NLM Clinical T
418 NLM Clinical Trials Questionnaire _2-14-11 414 ePSS, 415 FCIC 11Feb2011, 416 FCIC Pueblo 11Feb2011, 417 Howto.gov 3.7.2011 , 418 NLM Clinical Trials, 419 CMS Palmetto GBA J11 MAC, 420 Recreation.gov 2-4-2011 to 3-25-11, 421 DHHS-PSC , 422 DOT		 Form
Form 419 CMS Palmetto G
419 CMS Palmetto GBA J11 MAC Questionnaire 3-10-11 414 ePSS, 415 FCIC 11Feb2011, 416 FCIC Pueblo 11Feb2011, 417 Howto.gov 3.7.2011 , 418 NLM Clinical Trials, 419 CMS Palmetto GBA J11 MAC, 420 Recreation.gov 2-4-2011 to 3-25-11, 421 DHHS-PSC , 422 DOT		 Form
Form 420 CQs for OMB 2-
420 CQs for OMB 2-4-2011 to 3-25-11 414 ePSS, 415 FCIC 11Feb2011, 416 FCIC Pueblo 11Feb2011, 417 Howto.gov 3.7.2011 , 418 NLM Clinical Trials, 419 CMS Palmetto GBA J11 MAC, 420 Recreation.gov 2-4-2011 to 3-25-11, 421 DHHS-PSC , 422 DOT		 Form
Form 421 DHHS-PSC Offli
421 DHHS-PSC Offline Services Questionnaire 02-25-11 414 ePSS, 415 FCIC 11Feb2011, 416 FCIC Pueblo 11Feb2011, 417 Howto.gov 3.7.2011 , 418 NLM Clinical Trials, 419 CMS Palmetto GBA J11 MAC, 420 Recreation.gov 2-4-2011 to 3-25-11, 421 DHHS-PSC , 422 DOT		 Form
Form 422 DOT FHWA Quest
422 DOT FHWA Questionnaire 02-17-2011 414 ePSS, 415 FCIC 11Feb2011, 416 FCIC Pueblo 11Feb2011, 417 Howto.gov 3.7.2011 , 418 NLM Clinical Trials, 419 CMS Palmetto GBA J11 MAC, 420 Recreation.gov 2-4-2011 to 3-25-11, 421 DHHS-PSC , 422 DOT		 Form
414 ePSS Questionn 414 ePSS Questionnaire Wave 1 Revised
2011 414 ePSS Questionnaire Wave 1 Revised.xlsx 		Form
415 FCIC Consumer 415 FCIC Consumer Action CQ revisions_11Feb2011
2011 415 FCIC Consumer Action CQ revisions_11Feb2011.xlsx 		Form
416 FCIC Pueblo Su 416 FCIC Pueblo Survey revisions_11Feb2011
2011 416 FCIC Pueblo Survey revisions_11Feb2011.xlsx 		Form
417 Howto.gov Surv 417 Howto.gov Survey 3.7.2011 - current
2011 417 Howto.gov Survey 3.7.2011 - current.xlsx 		Form
418 NLM Clinical T 418 NLM Clinical Trials Questionnaire _2-14-11
2011 418 NLM Clinical Trials Questionnaire _2-14-11.xls 		Form
419 CMS Palmetto G 419 CMS Palmetto GBA J11 MAC Questionnaire 3-10-11
2011 419 CMS Palmetto GBA J11 MAC Questionnaire 3-10-11.xlsx 		Form
420 CQs for OMB 2- 420 CQs for OMB 2-4-2011 to 3-25-11
2011 420 CQs for OMB 2-4-2011 to 3-25-11.xlsx 		Form
421 DHHS-PSC Offli 421 DHHS-PSC Offline Services Questionnaire 02-25-11
2011 421 DHHS-PSC Offline Services Questionnaire 02-25-11.xlsx 		Form
422 DOT FHWA Quest 422 DOT FHWA Questionnaire 02-17-2011
2011 422 DOT FHWA Questionnaire 02-17-2011.xlsx 		Form

Information Collection (IC) Details

View Information Collection (IC)

layout table

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 414 ePSS Questionnaire Wave 1 Revised 414 ePSS Questionnaire Wave 1 Revised 2011 414 ePSS Questionnaire Wave 1 Revised.xlsx Yes Yes Fillable Fileable
Form 415 FCIC Consumer Action CQ revisions_11Feb2011 415 FCIC Consumer Action CQ revisions_11Feb2011 2011 415 FCIC Consumer Action CQ revisions_11Feb2011.xlsx Yes Yes Fillable Fileable
Form 416 FCIC Pueblo Survey revisions_11Feb2011 416 FCIC Pueblo Survey revisions_11Feb2011 2011 416 FCIC Pueblo Survey revisions_11Feb2011.xlsx Yes Yes Fillable Fileable
Form 417 Howto.gov Survey 3.7.2011 - current 417 Howto.gov Survey 3.7.2011 - current 2011 417 Howto.gov Survey 3.7.2011 - current.xlsx Yes Yes Fillable Fileable
Form 418 NLM Clinical Trials Questionnaire _2-14-11 418 NLM Clinical Trials Questionnaire _2-14-11 2011 418 NLM Clinical Trials Questionnaire _2-14-11.xls Yes Yes Fillable Fileable
Form 419 CMS Palmetto GBA J11 MAC Questionnaire 3-10-11 419 CMS Palmetto GBA J11 MAC Questionnaire 3-10-11 2011 419 CMS Palmetto GBA J11 MAC Questionnaire 3-10-11.xlsx Yes Yes Fillable Fileable
Form 420 CQs for OMB 2-4-2011 to 3-25-11 420 CQs for OMB 2-4-2011 to 3-25-11 2011 420 CQs for OMB 2-4-2011 to 3-25-11.xlsx Yes Yes Fillable Fileable
Form 421 DHHS-PSC Offline Services Q's 02-25-11 421 DHHS-PSC Offline Services Questionnaire 02-25-11 2011 421 DHHS-PSC Offline Services Questionnaire 02-25-11.xlsx Yes Yes Fillable Fileable
Form 422 DOT FHWA Questionnaire 02-17-2011 422 DOT FHWA Questionnaire 02-17-2011 2011 422 DOT FHWA Questionnaire 02-17-2011.xlsx Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 45,000 0 45,000 0 0 0
Annual IC Time Burden (Hours) 1,875 0 1,875 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.