Certified Nursing Assistants - Telephone Survey

Research to Inform the Prevention of Asthma in Healthcare

Documents and Forms

Document Name Document Type
Certified Nursing Assistants - Telephone Survey Form
Telephone Survey Appendix K_(3).docx.doc Form
Appendix L_(3).doc Spanish Language Survey IC Document

Information Collection (IC) Details

IC Title:	Certified Nursing Assistants - Telephone 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	Telephone Survey	Appendix K_(3).docx.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 594	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	594	594
Annual IC Time Burden (Hours)	297	297
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Spanish Language Survey	Appendix L_(3).doc	04/10/2013

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