Information Collection

CE Survey Form

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.