Information Collection

CE Survey Form

IC 210867 under ICR 201403-0915-007 · OMB 0915-0380.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 CE Survey Form	Form and Instruction
1 questionnaire Instrument.docx	Form and Instruction
Confidentiality Agreement.docx Confidentiality Agreement	IC Document
Informed Consent.docx Informed Consent	IC Document

IC Title:

CE Survey Form

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
Form and Instruction	1	questionnaire	Instrument.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,569

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	1,569	1,569
Annual IC Time Burden (Hours)	251	251
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Confidentiality Agreement	Confidentiality Agreement.docx	03/20/2014
Informed Consent	Informed Consent.docx	03/20/2014

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