Information Collection

Resident Pre-Focus Group Survey - ME, MN, FL

IC 204433 under ICR 201210-0920-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Resident Pre-Focus Group Survey - ME, MN, FL	Form
Pre-Focus Group Survey Att 13A_Resident Pre-Focus Group Survey.docx	Form
Att 13A-1_Focus Group Consent.docx Consent	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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
Form	none	Pre-Focus Group Survey	Att 13A_Resident Pre-Focus Group Survey.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

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 Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent	Att 13A-1_Focus Group Consent.docx	09/27/2012

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