Solve the Outbreak iPad Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Documents and Forms

Document Name Document Type
Solve the Outbreak iPad Survey Form
Survey STO_screenshots.pdf Form
Surveytemplate _SolvetheOutbreak.docx Request for Approval IC Document
Solve the Outbreak User Zoom Questions.docx Survey - Word version IC Document

Information Collection (IC) Details

IC Title:	Solve the Outbreak iPad Survey	Agency IC Tracking Number:

IC Status: Modified

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	none	Survey	STO_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: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	417	417
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval	Surveytemplate _SolvetheOutbreak.docx	06/26/2013
Survey - Word version	Solve the Outbreak User Zoom Questions.docx	06/26/2013

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