KSN Annual Feedback Survey Year 3

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⚠️ Notice: This information collection may be referencing outdated material.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
KSN Annual Survey Instrument_non-response short follow-up_FINAL.docx Other-survey
KSN Annual Survey Instrument year 3_v8.docx Other-survey
OMB Submission KSN User Feedback Survey Year 3.zip Other-survey
OMB Submission KSN User Feedback Survey Year 3_Yesenko.docx OMB Submission KSN User Feedback Survey Year 3_Yesenko IC Document

Information Collection (IC) Details

IC Title:	KSN Annual Feedback Survey Year 3	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-survey	KSN Annual Survey Instrument_non-response short follow-up_FINAL.docx	Yes	Yes	Fillable Printable
Other-survey	KSN Annual Survey Instrument year 3_v8.docx	Yes	Yes	Fillable Printable
Other-survey	OMB Submission KSN User Feedback Survey Year 3.zip	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 367	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

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	367	0	0	0	0	0
Annual IC Time Burden (Hours)	77	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
OMB Submission KSN User Feedback Survey Year 3_Yesenko	OMB Submission KSN User Feedback Survey Year 3_Yesenko.docx	01/11/2013

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