Information Collection

Prevention Is Care (PIC) Paper and Pencil Questionnaire

IC 183190 under ICR 201104-0920-002 · OMB 0920-0775.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Prevention Is Care (PIC) Paper and Pencil Questionnaire	Form
PIC Paper and Pencil Questionnaire A7b Paper and Pencil Survey-PIC.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	none	PIC Paper and Pencil Questionnaire	A7b Paper and Pencil Survey-PIC.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

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	Previously Approved
Annual Number of Responses for this IC	54	54
Annual IC Time Burden (Hours)	9	9
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.