Information Collection

Client Opinion Form

IC 202876 under ICR 201206-0915-006 · OMB 0915-0346.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 13a Client Opinion Form	Form and Instruction
13 Clinet Opinion Form ClientOpinionForm_2012_08_28 - REVISED.doc	Form and Instruction
13a Clinet Opinon Form Spanish ClientOpinionForm_SPANISH_2012_08_28 - REVISED.doc	Form and Instruction

IC Title:

Client Opinion Form

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	13a	Clinet Opinon Form Spanish	ClientOpinionForm_SPANISH_2012_08_28 - REVISED.doc		Yes	Yes	Fillable Fileable
Form and Instruction	13	Clinet Opinion Form	ClientOpinionForm_2012_08_28 - REVISED.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 810

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	810	810
Annual IC Time Burden (Hours)	95	95
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.