eConsent surveys

Comprehensive Communication Campaign for HITECH ACT

Documents and Forms

Document Name Document Type
0990-0376_20111215_eConsent_Survey_v1.docx Other-survey
0990-0376_eConsent surveyMini Supporting Statement Approved Generic.docx 0990-0376_eConsent surveyMini Supporting Statement Approved Generic IC Document
0990-0376_20111215_eConsent_cover_letter_v1.docx 0990-0376_20111215_eConsent_cover_letter_v1 IC Document

Information Collection (IC) Details

IC Title:	eConsent surveys	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			0990-0376_20111215_eConsent_Survey_v1.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	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	2,800	0	0	0	0	0
Annual IC Time Burden (Hours)	233	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
0990-0376_eConsent surveyMini Supporting Statement Approved Generic	0990-0376_eConsent surveyMini Supporting Statement Approved Generic.docx	12/21/2011
0990-0376_20111215_eConsent_cover_letter_v1	0990-0376_20111215_eConsent_cover_letter_v1.docx	12/21/2011

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