Information Collection

Survey Respondents

IC 200924 under ICR 201208-0955-005 · OMB 0955-0005.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0955-0005 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-0376_Survey for Developing Education for Sharing Patient Medical Info_eConsent_Survey_v1.docx	Other-survey
0990-0376_Survey for Developing Education for Sharing Patient Medical Info_eConsent_cover_letter_v1.docx 0990-0376_Survey for Developing Education for Sharing Patient Medical Info_eConsent_cover_letter_v1	IC Document
0990-0376_Mini Supporting Statement Cognitive Testing Consumer Privacy Security.docx mini supporting st	IC Document

IC Title:

Survey Respondents

Agency IC Tracking Number:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-survey			0990-0376_Survey for Developing Education for Sharing Patient Medical Info_eConsent_Survey_v1.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	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	2,800	0	0	0	0	0
Annual IC Time Burden (Hours)	233	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0990-0376_Survey for Developing Education for Sharing Patient Medical Info_eConsent_cover_letter_v1	0990-0376_Survey for Developing Education for Sharing Patient Medical Info_eConsent_cover_letter_v1.docx	01/10/2012
mini supporting st	0990-0376_Mini Supporting Statement Cognitive Testing Consumer Privacy Security.docx	01/10/2012

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