Information Collection

Customer Satisfaction with the 2012 Guide to Clinical Preventive Services

IC 203561 under ICR 201104-0935-006 · OMB 0935-0179.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0179 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 Customer Satisfaction with the 2012 Guide to Clinical Preventive Services	Form
Form #1 Guide to Clinical Preventive Services Feedback Questionn Attachment A -- Guide to Clinical Preventive Services Feedback Questionnaire BC.docx	Form
OMB Submission Form -- Customer Satisfaction with the 2012 Guide to Clinical Preventive Services.docx OMB Submission Form -- Customer Satisfaction with the 2012 Guide to Clinical Preventive Services	IC Document

IC Title:

Customer Satisfaction with the 2012 Guide to Clinical Preventive Services

Agency IC Tracking Number:

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	Form #1	Guide to Clinical Preventive Services Feedback Questionnaire	Attachment A -- Guide to Clinical Preventive Services Feedback Questionnaire BC.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

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	5,000	0	0	0	0	0
Annual IC Time Burden (Hours)	167	0	0	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
OMB Submission Form -- Customer Satisfaction with the 2012 Guide to Clinical Preventive Services	OMB Submission Form -- Customer Satisfaction with the 2012 Guide to Clinical Preventive Services.docx	08/02/2012

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