Information Collection

Solve the Outbreak iPad Survey

IC 207575 under ICR 201402-0920-015 · OMB 0920-0956.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

IC Status: Modified

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.