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
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	Mock-up Screen Shots Supplement SOTS Survey	Attachment G - SOTS Supplement 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: 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	Attachment F-SOTS Supplement.docx	02/13/2013

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