Information Collection

Map Your Social Network

IC 209617 under ICR 201403-0925-011 · OMB 0925-0700.

Documents and Forms

Document Name Document Type
Form 1 Map Your Social Network Form and Instruction
1 Screenshot: Map Your Social Network Attach 7. Screenshot Map Your Social Network-Koehly.pdf Form and Instruction
Attach 6. Survey Map Your Social Network-Koehly.pdf Attach 6 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Map Your Social Network	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	Screenshot: Map Your Social Network	Attach 7. Screenshot Map Your Social Network-Koehly.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	17,500	17,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attach 6	Attach 6. Survey Map Your Social Network-Koehly.pdf	03/24/2014

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