Information Collection

Solve the Outbreak iPad Survey

IC 207575 under ICR 201303-0920-011 · OMB 0920-0956.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0956 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Solve the Outbreak iPad Survey	Form
Survey STO_screenshots.docx	Form
Surveytemplate _SolvetheOutbreak.docx Request for Approval	IC Document
Solve the Outbreak User Zoom Questions.docx Survey - Word version	IC Document

IC Title:

Solve the Outbreak iPad Survey

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
Form	none	Survey	STO_screenshots.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	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	5,000	0	0	0	0	0
Annual IC Time Burden (Hours)	417	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
Request for Approval	Surveytemplate _SolvetheOutbreak.docx	06/26/2013
Survey - Word version	Solve the Outbreak User Zoom Questions.docx	06/26/2013

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