Feedback Questionnaire for Patients Requesting Mailed Guides

Assessing the Feasibility of Disseminating Effective Health Center Products through Mobile Phone Applications

Documents and Forms

Document Name Document Type
Form Form #4 Feedback Questionnaire for Patients Requesting Mailed Guides Form
Form #4 Feedback Questionnaire for Patients Requesting Mailed Gu Attachment F -- Feedback Questionnaire for Patients Requesting Mailed Guides.docx Form

Information Collection (IC) Details

IC Title:	Feedback Questionnaire for Patients Requesting Mailed Guides	Agency IC Tracking Number:

Is this a Common Form? No		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	Form #4	Feedback Questionnaire for Patients Requesting Mailed Guides	Attachment F -- Feedback Questionnaire for Patients Requesting Mailed Guides.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

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

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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