Information Collection

District Collaborator Survey

IC 213251 under ICR 201409-0930-002 · OMB 0930-0347.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form District Collabora District Collaborator Survey	Form and Instruction
District Collabora District Collaborator Survey Attachment D_District Collaborator Survey.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	District Collaborator Survey	District Collaborator Survey	Attachment D_District Collaborator Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 624

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	624	624
Annual IC Time Burden (Hours)	206	206
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.