Information Collection

Participant Feedback

IC 211984 under ICR 201406-0925-002 · OMB 0925-0584.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Participant Feedback Participant Feedback	Form and Instruction
1 Participant Feedback PFE-Participant Feedback-Eng.pdf	Form and Instruction
PFS-Participant Feedback-Span.pdf Participant Feedback	IC Document

IC Title:

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				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)	2,776	2,776
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Participant Feedback		06/19/2014

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

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