Emergency Departments Paper and Pencil Questionnaire

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Documents and Forms

Document Name Document Type
Emergency Departments Paper and Pencil Questionnaire Form
Emergency Dept Paper and Pencil Questionnaire A7a Paper and Pencil Survey-Routine Testing.docx Form

Information Collection (IC) Details

IC Title:	Emergency Departments Paper and Pencil Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	none	Emergency Dept Paper and Pencil Questionnaire	A7a Paper and Pencil Survey-Routine Testing.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8	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	Previously Approved
Annual Number of Responses for this IC	8	-16	24
Annual IC Time Burden (Hours)	1	-3	4
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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