Certified Nursing Assistants - Online Survey

Research to Inform the Prevention of Asthma in Healthcare

Documents and Forms

Document Name Document Type
Certified Nursing Assistants - Online Survey Form
Survey Web version Appendix M_(3).docx Form
Appendix J_(3.docx Survey Instructions IC Document

Information Collection (IC) Details

IC Title:	Certified Nursing Assistants - Online Survey	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	none	Survey Web version	Appendix M_(3).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 149	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	149	149
Annual IC Time Burden (Hours)	75	75
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Survey Instructions	Appendix J_(3.docx	04/10/2013

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