Information Collection

Web Survey: Fact Sheet, Factsheet Testing Screenshots, Video Testing, and Testing Screenshots

IC 202908 under ICR 201206-0920-007 · OMB 0920-0947.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Web Survey: Fact Sheet, Factsheet Testing Screenshots, Video Testing, and Testing Screenshots	Form and Instruction
Web Survey Attachment 3E Web Survey Screener Screenshots Rev 9 5.docx	Form and Instruction
Web Survey Factsheet Attachment 3G Web Survey Factsheet Testing Screenshots Rev 9 5.docx	Form and Instruction
Web Survey Video Attachment 3I Web Survey Video Testing Screenshots Rev 9 5.docx	Form and Instruction
Attachment 3F Web Survey_Factsheet Testing (rev08272012).docx Attachment 3F Web Survey_Factsheet Testing (rev08272012)	IC Document
Attachment 3H Web Survey_Video Testing (rev 08272012).docx Attachment 3H Web Survey_Video Testing (rev 08272012)	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	Available Electronically?	Electronic Capability
Form and Instruction	none	Web Survey Factsheet	Attachment 3G Web Survey Factsheet Testing Screenshots Rev 9 5.docx	No	Paper Only
Form and Instruction	none	Web Survey Video	Attachment 3I Web Survey Video Testing Screenshots Rev 9 5.docx	No	Paper Only
Form and Instruction	none	Web Survey	Attachment 3E Web Survey Screener Screenshots Rev 9 5.docx	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	147	147
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 3F Web Survey_Factsheet Testing (rev08272012)	Attachment 3F Web Survey_Factsheet Testing (rev08272012).docx	09/07/2012
Attachment 3H Web Survey_Video Testing (rev 08272012)	Attachment 3H Web Survey_Video Testing (rev 08272012).docx	09/07/2012

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