Information Collection

Viewers Feedback Form

IC 198963 under ICR 201108-0930-001 · OMB 0930-0331.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachment 3 Viewers Feedback Form	Form and Instruction
Attachment 3 Video Viewers Feedback Form Attachment 3_Video Viewers Feedback Form.doc	Form and Instruction
Attachment 4_Report on UAD Prevention Videos A Four-State Pilot Project.pdf Report on UAD Prevention Video	IC Document
Attachment 5_ICF Macro IRB Review Findings Form_State-Territory Videos Project.pdf IRB	IC Document
Attachment 6_State-Territory Videos Project_Communications Sent Prior to Assessment.pdf Communications Sent Prior to Assessment	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	Attachment 3	Video Viewers Feedback Form	Attachment 3_Video Viewers Feedback Form.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,056

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,056	3,056
Annual IC Time Burden (Hours)	254	254
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Report on UAD Prevention Video	Attachment 4_Report on UAD Prevention Videos A Four-State Pilot Project.pdf	08/09/2011
IRB	Attachment 5_ICF Macro IRB Review Findings Form_State-Territory Videos Project.pdf	08/09/2011
Communications Sent Prior to Assessment	Attachment 6_State-Territory Videos Project_Communications Sent Prior to Assessment.pdf	08/09/2011

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