Information Collection

Participant Exit Satisfaction Survey

IC 210068 under ICR 201401-0925-005 · OMB 0925-0694.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Participant Exit Satisfaction Survey	Form and Instruction
3 Participant Exit Satisfaction Survey 3C - NDEP DHS Particpant Exit Satisfaction Survey_121913_OMB30.pdf	Form and Instruction
3C - NDEP DHS Participant Exit Satisfaction Survey_091913_OMB30.doc 3C - NDEP DHS Participant Exit Satisfaction Survey_091913_OMB30	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 and Instruction	3	Participant Exit Satisfaction Survey	3C - NDEP DHS Particpant Exit Satisfaction Survey_121913_OMB30.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

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	200	200
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
3C - NDEP DHS Participant Exit Satisfaction Survey_091913_OMB30	3C - NDEP DHS Participant Exit Satisfaction Survey_091913_OMB30.doc	01/13/2014

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