Information Collection

Supplemental SOTS Survey Questions

IC 205808 under ICR 201401-0920-005 · OMB 0920-0916.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Mock-up Screen Shots Supplement SOTS Survey Supplemental SOTS Survey Questions	Form
Mock-up Screen Shots Supplement SOTS Survey Attachment G - SOTS Supplement Screenshots.pdf	Form
Attachment F-SOTS Supplement.docx Word Version - Supplemental SOTS Survey	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 28

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-28	28
Annual IC Time Burden (Hours)	-42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Word Version - Supplemental SOTS Survey		02/13/2013

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

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