Follow-up Web Survey

Study to Explore Educational Children's Book in Pediatric Offices

Documents and Forms

Document Name Document Type
Follow-up Web Survey Form
Follow-up Survey Attachment 4a Amazing Me Parent Follow-Up Contact Survey Screenshots.pdf Form
Attachment 4 Amazing Me Parent Follow-Up Contact Survey FINAL Mar 15 2013.docx Follow-up Survey - Word IC Document

Information Collection (IC) Details

IC Title:	Follow-up Web 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	Follow-up Survey	Attachment 4a Amazing Me Parent Follow-Up Contact Survey Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 900	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	900	900
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Follow-up Survey - Word	Attachment 4 Amazing Me Parent Follow-Up Contact Survey FINAL Mar 15 2013.docx	07/22/2013

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