Information Collection

Map Your Social Network

IC 209617 under ICR 201312-0925-004 · OMB 0925-0700.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0700 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Map Your Social Network	Form and Instruction
1 Map your social network Attach 7. Screenshot Map Your Social Network-Koehly.pdf	Form and Instruction
Attach 6. Survey Map Your Social Network-Koehly.pdf Attach 6	IC Document

IC Title:

Map Your Social Network

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 and Instruction	1	Map your social network	Attach 7. Screenshot Map Your Social Network-Koehly.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	17,500	17,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attach 6	Attach 6. Survey Map Your Social Network-Koehly.pdf	11/13/2013

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