Survey

Fast Track Generic Clearance for Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0401 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Survey Form and Instruction
1 Survey Survey Instrument.docx Form and Instruction
Short Form.docx Short Submission Form IC Document

Information Collection (IC) Details

IC Title:	Survey	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 and Instruction	1	Survey	Survey Instrument.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11,000	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	11,000	0	0	0	0	0
Annual IC Time Burden (Hours)	183	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Short Submission Form	Short Form.docx	08/08/2012

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