Information Collection

Survey

IC 209574 under ICR 201312-0920-003 · OMB 0920-1007.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Survey	Form
Survey - screenshots Appendix C2 Screenshots of Survey Questionnaire_Revised _120313..pdf	Form
Survey - Word Appendix C1 CBS National Survey_Questionaire_Revised 120313.docx	Form
Appendix D1 Study_Invitation_Letter_10 28 2013.docx D1 - Invitation Letter	IC Document
Appendix D2 Study Fact Sheet_12032013.docx D2 - Study Fact Sheet	IC Document
Appendix D3 Instructions for Accessing the Web Survey_12032013.docx D3 - Instructions for Accessing Survey	IC Document

IC Title:

Survey

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	Survey - screenshots	Appendix C2 Screenshots of Survey Questionnaire_Revised _120313..pdf		Yes	Yes	Fillable Fileable
Form	none	Survey - Word	Appendix C1 CBS National Survey_Questionaire_Revised 120313.docx		No	No	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,139

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,139	3,139
Annual IC Time Burden (Hours)	1,570	1,570
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
D1 - Invitation Letter	Appendix D1 Study_Invitation_Letter_10 28 2013.docx	12/04/2013
D2 - Study Fact Sheet	Appendix D2 Study Fact Sheet_12032013.docx	12/04/2013
D3 - Instructions for Accessing Survey	Appendix D3 Instructions for Accessing the Web Survey_12032013.docx	12/04/2013

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