Information Collection

Psr

IC 214223 under ICR 201402-0920-018 · OMB 0920-0879.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
F_Online Instrument - Web Version.docx	Other-Web
E_Online Instrument - Word version.docx	Other-WORD
G_Interview Guide.docx	Other-WORD
GEL2-PSR-SSA.docx Supporting Statement A	IC Document
GEL2-PSR-SSB.docx Supporting Statement B	IC Document
A_Georgia PSR.pdf Att A_Georgia PSR	IC Document
B_PSR Quick Start Guide.docx Att B_PSR Quick Start Guide	IC Document
C_PSR National Summary.pdf Att C_ PSR National Summary	IC Document
D_PSR 2011 Assessment Results.docx Att D_ PSR 2011 Assessment Results	IC Document
H_Web Assessment Notification Email.docx Att H_Assessment Notification E-mail	IC Document
I_Web Assessment Reminder Email.docx Att I_Assessment Reminder Email	IC Document
J_Interview Notification Email.docx Att J_Interview Notification Email	IC Document
K_Interview Follow-Up Email.docx Att K_Interview F/U Email	IC Document

IC Title:

PSR

Agency IC Tracking Number:

15HA

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Web	F_Online Instrument - Web Version.docx	Yes	Yes	Fillable Printable
Other-WORD	E_Online Instrument - Word version.docx	Yes	Yes	Fillable Printable
Other-WORD	G_Interview Guide.docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 632

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	632	632
Annual IC Time Burden (Hours)	160	160
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	GEL2-PSR-SSA.docx	12/11/2014
Supporting Statement B	GEL2-PSR-SSB.docx	12/11/2014
Att A_Georgia PSR	A_Georgia PSR.pdf	12/11/2014
Att B_PSR Quick Start Guide	B_PSR Quick Start Guide.docx	12/11/2014
Att C_ PSR National Summary	C_PSR National Summary.pdf	12/11/2014
Att D_ PSR 2011 Assessment Results	D_PSR 2011 Assessment Results.docx	12/11/2014
Att H_Assessment Notification E-mail	H_Web Assessment Notification Email.docx	12/11/2014
Att I_Assessment Reminder Email	I_Web Assessment Reminder Email.docx	12/11/2014
Att J_Interview Notification Email	J_Interview Notification Email.docx	12/11/2014
Att K_Interview F/U Email	K_Interview Follow-Up Email.docx	12/11/2014

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