Information Collection

Resident Pre-Focus Group Survey

IC 208868 under ICR 201309-0920-011 · OMB 0920-1004.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Resident Pre-Focus Group Survey Resident Pre-Focus Group Survey	Form
Resident Pre-Focus Group Survey Att 13A_Resident Pre-Focus Group Survey_9.3.13.docx	Form
Att 13A-1_Focus Group Consent_9.3.13.docx Consent	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				Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent		09/23/2013

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

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