Customer Satisfaction Survey of Preconception Health Adcepts

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0919 can be found here:

Documents and Forms

Document Name Document Type
Customer Satisfaction Survey of Preconception Health Adcepts Form
Screener Attach 1_SCREENER.docx Form
Customer Service Survey Attach 2_CONCEPT TESTING SURVEY Updated 2-22-2012.doc Form
Attach 3_PCH Survey_Screen shots.docx Survey Screenshots IC Document
Supplemental 1_PCH 1-04-12b ADCEPTS.pdf Adcepts IC Document
Supp2_ALL12LOGO OPTIONSFORSURVEY final_options.pptx Logo Options IC Document
Supp3_Q10a non-planner text.jpg Non-planner Text IC Document
DraftGenClrnceSubTemplate_CusSatSvy (revised 02012012).docx genIC Application IC Document

Information Collection (IC) Details

IC Title:	Customer Satisfaction Survey of Preconception Health Adcepts	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
Form	none	Screener	Attach 1_SCREENER.docx		Yes	Yes	Fillable Fileable
Form	none	Customer Service Survey	Attach 2_CONCEPT TESTING SURVEY Updated 2-22-2012.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	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	3,200	0	0	0	0	0
Annual IC Time Burden (Hours)	375	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Survey Screenshots	Attach 3_PCH Survey_Screen shots.docx	02/29/2012
Adcepts	Supplemental 1_PCH 1-04-12b ADCEPTS.pdf	02/29/2012
Logo Options	Supp2_ALL12LOGO OPTIONSFORSURVEY final_options.pptx	02/29/2012
Non-planner Text	Supp3_Q10a non-planner text.jpg	02/29/2012
genIC Application	DraftGenClrnceSubTemplate_CusSatSvy (revised 02012012).docx	02/29/2012

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