Information Collection

Participant Exit Satisfaction Survey

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Participant Exit Satisfaction Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.