Information Collection

Participating Employer - Pilot Training: Online Model Evaluation Survey

IC 208008 under ICR 201308-0920-001 · OMB 0920-0989.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Participating Employer - Pilot Training: Online Model Evaluation Survey	Form
Online Pilot Screenshots Attachment F-2_Screen Shots Online Pilot Eval_6-27-13.doc	Form
Attachment F-1_Online Eval Survey_6-25-13.doc Online Model Evaluation Survey Form	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	Online Pilot Screenshots	Attachment F-2_Screen Shots Online Pilot Eval_6-27-13.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

Number of Respondents for Small Entity: 15

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Online Model Evaluation Survey Form	Attachment F-1_Online Eval Survey_6-25-13.doc	07/25/2013

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