Information Collection

Well Being

IC 211979 under ICR 201406-0925-002 · OMB 0925-0584.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Well Being	Form and Instruction
1 Well Being WBE-Well Being-Eng.pdf	Form and Instruction
WBS- Wellbeing-Span.pdf Well Being	IC Document

IC Title:

Well Being

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	Well Being	WBE-Well Being-Eng.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13,878

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	13,878	13,878
Annual IC Time Burden (Hours)	925	925
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Well Being	WBS- Wellbeing-Span.pdf	06/19/2014

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