TB Laboratory Site Visit Evaluation Six-Month Follow-Up-Online Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCHHSTP)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1027 can be found here:

Documents and Forms

Document Name Document Type
TB Laboratory Site Visit Evaluation Six-Month Follow-Up-Online Survey Form
Appendix 1_Survey Questions_Site Visit Evaluation_ Six m Appendix 1_Survey Questions_Site Visit Evaluation_ Six month Follow-up.docx Form
Appendix 2_Web Shots_Survey Questions_Site Visit Evaluat Appendix 2_Web Shots_Survey Questions_Site Visit Evaluation_Six Month Follow-up.docx Form
Template-Customer Feedback_ TB Site Visit_Online.docx Template-Customer Feedback_ TB Site Visit_Online IC Document
Appendix 3_Web Shot_Reminder email.docx Appendix 3_Web Shot_Reminder email IC Document

Information Collection (IC) Details

IC Title:	TB Laboratory Site Visit Evaluation Six-Month Follow-Up-Online Survey	Agency IC Tracking Number:	17AAM

IC Status: New

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	N/A	Appendix 1_Survey Questions_Site Visit Evaluation_ Six month Follow-up	Appendix 1_Survey Questions_Site Visit Evaluation_ Six month Follow-up.docx		Yes	Yes	Fillable Fileable
Form	N/A	Appendix 2_Web Shots_Survey Questions_Site Visit Evaluation_Six Month Follow-up	Appendix 2_Web Shots_Survey Questions_Site Visit Evaluation_Six Month Follow-up.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 58	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	58	58
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Template-Customer Feedback_ TB Site Visit_Online	Template-Customer Feedback_ TB Site Visit_Online.docx	03/23/2017
Appendix 3_Web Shot_Reminder email	Appendix 3_Web Shot_Reminder email.docx	03/23/2017

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