Information Collection

NHSC Site Retention Assessment Questionnaire

IC 205949 under ICR 201302-0915-002 · OMB 0915-0372.

Documents and Forms

Document Name Document Type
Form 1 NHSC Site Retention Assessment Questionnaire Form and Instruction
1 NHSC Site Retention Assessment Questionnaire NHSC Site Retention Assessment Questionnaire_FINAL_amended_12132013.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NHSC Site Retention Assessment Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		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 and Instruction	1	NHSC Site Retention Assessment Questionnaire	NHSC Site Retention Assessment Questionnaire_FINAL_amended_12132013.pdf		No		Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,000	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,000	7,000
Annual IC Time Burden (Hours)	3,549	3,549
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.