Information Collection

180-day Follow-up Survey

IC 198814 under ICR 201406-0920-006 · OMB 0920-0896.

Documents and Forms

Document Name Document Type
180-day Follow-up Survey Form
180 day Follow up Survey att3b_180-Day Follow-up Survey.doc Form
180 day Follow up Survey - screenshots CMEP_WILLOW_OMB_SS_180_day.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	180-day Follow-up Survey	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	none	180 day Follow up Survey	att3b_180-Day Follow-up Survey.doc		Yes	Yes	Fillable Fileable
Form	none	180 day Follow up Survey - screenshots	CMEP_WILLOW_OMB_SS_180_day.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 320	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	320	320
Annual IC Time Burden (Hours)	96	96
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.