Safety Net Consumer Survey Round 1

Evaluation of the Text4baby Program

Documents and Forms

Document Name Document Type
Form 1 Safety Net Consumer Survey Round 1 Form
1 Safety Net Consumer Survey R1 Round1 HPP Survey 08_16_2012.docx Form

Information Collection (IC) Details

IC Title:	Safety Net Consumer Survey Round 1	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	1	Safety Net Consumer Survey R1	Round1 HPP Survey 08_16_2012.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 960	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	960	960
Annual IC Time Burden (Hours)	317	317
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.