Information Collection

Online Survey Instrument

IC 192388 under ICR 201304-0920-020 · OMB 0920-0600.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0600 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Online Survey Instrument	Form and Instruction
Attachment H: Screen Shots of Survey Instrument Att H Survey Instrument-Web shots.docx	Form and Instruction

IC Title:

Online Survey Instrument

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 and Instruction	none	Attachment H: Screen Shots of Survey Instrument	Att H Survey Instrument-Web shots.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 93

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	186	120	66
Annual IC Time Burden (Hours)	47	14	33
Annual IC Cost Burden (Dollars)	0	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.