Information Collection

Application Survey

IC 204865 under ICR 201211-3170-005 · OMB 3170-0030.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3170-XXXX Consent for Participation in Research Application Survey	Form and Instruction
Form 3170-XXXX Application Survey & Script Application Survey	Form and Instruction
Script for Introducing the Research Study FINAL.pdf	Instruction
3170-XXXX Consent for Participation in Research Consent for Participation in Research FINAL.pdf	Form and Instruction
3170-XXXX Application Survey & Script Application Survey & Script FINAL.pdf	Form and Instruction

IC Title:

Application Survey

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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		Yes	No	Printable Only
Form and Instruction	3170-XXXX	Yes	No	Fillable Printable
Form and Instruction	3170-XXXX	Yes	No	Fillable Printable

Line of Business: Economic Development

Subfunction: Financial Sector Oversight

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.

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