Information Collection

2012 IRG Stakeholder Survey

IC 206542 under ICR 201108-0925-006 · OMB 0925-0474.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0474 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 2012 IRG Stakeholder Survey	Form and Instruction
1 2012 IRG Stakeholder Survey 2012 IRG Stakeholder Survey Screenshot 4.2013.pdf	Form and Instruction
IRG Stakeholder Memo ver2 4.2103.doc 2012 IRG Stakeholder Survey Justification Memo	IC Document
2012 IRG StakeholderSurvey Generic Template MemoCSR ver2 4.2013.doc 2012 IRH Stakeholder Survey - Generic Template	IC Document

IC Title:

2012 IRG Stakeholder Survey

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 and Instruction	1	2012 IRG Stakeholder Survey	2012 IRG Stakeholder Survey Screenshot 4.2013.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 180

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	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	180	0	0	0	0	0
Annual IC Time Burden (Hours)	45	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
2012 IRG Stakeholder Survey Justification Memo	IRG Stakeholder Memo ver2 4.2103.doc	04/15/2013
2012 IRH Stakeholder Survey - Generic Template	2012 IRG StakeholderSurvey Generic Template MemoCSR ver2 4.2013.doc	04/15/2013

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