Information Collection

Survey Instrument

IC 210863 under ICR 201403-0925-008 · OMB 0925-0696.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Survey Instrument	Form and Instruction
1 Survey Instrument Attachment 3 NHLBI Protocol 13-H-0183 Survey Instrument.doc	Form and Instruction

IC Title:

Survey Instrument

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	Survey Instrument	Attachment 3 NHLBI Protocol 13-H-0183 Survey Instrument.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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