Information Collection

Pre-test

IC 198731 under ICR 201108-0935-001 · OMB 0935-0188.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #2 Pre-test	Form and Instruction
Form #2 Assisted Living Provider Information Tool for Consumer E Attachment D -- AL Provider Info Tool for Consumer Education.pdf	Form and Instruction
Attachment H -- Recruitment Letter, Brochure & Followup Postcards.docm Attachment H -- Recruitment Letter, Brochure & Followup Postcards	IC Document

IC Title:

Pre-test

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	Form #2	Assisted Living Provider Information Tool for Consumer Education	Attachment D -- AL Provider Info Tool for Consumer Education.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 191

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 Agency Discretion
Annual Number of Responses for this IC	191	191
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment H -- Recruitment Letter, Brochure & Followup Postcards	Attachment H -- Recruitment Letter, Brochure & Followup Postcards.docm	07/28/2011

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