Information Collection

Attachment E: Secondary Trainee One-time 12-month Survey

IC 212070 under ICR 201406-0935-001 · OMB 0935-0220.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Attachment E: Secondary Trainee One-time 12-month Survey	Form and Instruction
5 Attachment E: Secondary Trainee One-time 12-month Survey ATTACHMENT E_Survey5-Secondary Trainee One-time 6-24-14.docx	Form and Instruction

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	5	Attachment E: Secondary Trainee One-time 12-month Survey	ATTACHMENT E_Survey5-Secondary Trainee One-time 6-24-14.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,000

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	3,000	3,000
Annual IC Time Burden (Hours)	500	500
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.