Information Collection

CBS Survey

IC 201062 under ICR 201202-0920-003 · OMB 0920-0934.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CBS Survey	Form
CBS Questionnaire Appendix C1. CBS Questionnaire 01_19_12.doc	Form
Survey Screenshots Appendix C2. CBS Survey Screen Shots 11712.pdf	Form
Appendix D5. Instructions 01_19_12.doc Survey Instructions	IC Document

IC Title:

CBS Survey

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	CBS Questionnaire	Appendix C1. CBS Questionnaire 01_19_12.doc		Yes	Yes	Fillable Fileable
Form	none	Survey Screenshots	Appendix C2. CBS Survey Screen Shots 11712.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400

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	400	400
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey Instructions	Appendix D5. Instructions 01_19_12.doc	01/24/2012

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