Participant Self-Identification Information

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (HITRC)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0955-0003 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Participant Self-Identification Information Form
1 User Self-ID Registration Questions Cornell Planning Room.docx Form
Cornell Planning Room Supporting Statement A.docx Cornell Planning Room Supporting Statement A IC Document
Cornell Planning Room Supporting Statement B.docx Cornell Planning Room Supporting Statement B IC Document

Information Collection (IC) Details

IC Title:	Participant Self-Identification Information	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	1	User Self-ID Registration Questions	Cornell Planning Room.docx		No	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 175	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	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	175	0	0	0	0	0
Annual IC Time Burden (Hours)	175	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Cornell Planning Room Supporting Statement A	Cornell Planning Room Supporting Statement A.docx	01/03/2013
Cornell Planning Room Supporting Statement B	Cornell Planning Room Supporting Statement B.docx	01/03/2013

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