Stakeholder Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Program

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0179 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Stakeholder Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Program Form and Instruction
1 Questions for Stakeholders Customer Satisfaction Survey_stakeholder FINAL.docx Form and Instruction
Generic Clearance Submission_Stakeholders FINAL review.doc Supporting Statement Part A IC Document
OMB Cover Letter.doc Cover Letter IC Document

Information Collection (IC) Details

IC Title:	Stakeholder Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Program	Agency IC Tracking Number:

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 and Instruction	1	Questions for Stakeholders	Customer Satisfaction Survey_stakeholder FINAL.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement Part A	Generic Clearance Submission_Stakeholders FINAL review.doc	08/31/2016
Cover Letter	OMB Cover Letter.doc	08/31/2016

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