Information Collection

Quality of Life Survey

IC 199632 under ICR 201110-0920-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Quality of Life Survey	Form
Attachment_E_Survey_Screenshots.pdf	Other-Screen Shots
Quality of Life Survey Attachment_D_Survey-Instrument.docx	Form
Attachment_C_Survey-Invitation.docx Survey Invitation	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	none	Quality of Life Survey	Attachment_D_Survey-Instrument.docx		Yes	Yes	Fillable Fileable
Other-Screen Shots			Attachment_E_Survey_Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,850

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,850	1,850
Annual IC Time Burden (Hours)	771	771
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey Invitation	Attachment_C_Survey-Invitation.docx	09/27/2011

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