Information Collection

Remote Survey

IC 197622 under ICR 201105-0990-003 · OMB 0990-0321.

Documents and Forms

Document Name Document Type
0990-0321Attachment3.pdf Other-survey
0990-0321Attachment1.pdf 0990-0321Attachment1 IC Document
0990-0321Attachment4.pdf 0990-0321Attachment4 IC Document
0990-0321Attachment2.pdf 0990-0321Attachment2 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Remote Survey	Agency IC Tracking Number:

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
Other-survey			0990-0321Attachment3.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	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	4,800	0	0	0	0	0
Annual IC Time Burden (Hours)	960	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

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