Information Collection

Worksheet for Identifying Site Visit Interviews (Private Sector)

IC 210395 under ICR 201402-0920-013 · OMB 0920-1012.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 6e_Worksheet for Identifying Interviewees_12.17.13.docx	Other-WORD
Att 6f_Worksheet for Scheduling Interviews_12.17.13.docx	Other-WORD
Att 6d_Site Visit Preparation Call_02.10.2014.docx Att 6d_Site Visit Preparation Call_02	IC Document
Att 7a_Document Review Form_9.11.13.docx Att 7a_Document Review Form_9	IC Document
Att 7b_Observation Form_9.11.13.docx Att 7b_Observation Form_9	IC Document
Att 8_Interview Guide Matrix_12.18.13.docx Att 8_Interview Guide Matrix_12	IC Document
Att 9_Informed Consent_12.18.13.docx Att 9_Informed Consent_12	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
Other-WORD			Att 6e_Worksheet for Identifying Interviewees_12.17.13.docx		Yes	Yes	Fillable Printable
Other-WORD			Att 6f_Worksheet for Scheduling Interviews_12.17.13.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

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	7	7
Annual IC Time Burden (Hours)	7	7
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 6d_Site Visit Preparation Call_02	Att 6d_Site Visit Preparation Call_02.10.2014.docx	02/10/2014
Att 7a_Document Review Form_9	Att 7a_Document Review Form_9.11.13.docx	02/10/2014
Att 7b_Observation Form_9	Att 7b_Observation Form_9.11.13.docx	02/10/2014
Att 8_Interview Guide Matrix_12	Att 8_Interview Guide Matrix_12.18.13.docx	02/10/2014
Att 9_Informed Consent_12	Att 9_Informed Consent_12.18.13.docx	02/10/2014

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