Information Collection

Learn the Signs. Act Early. Partner Webinars

IC 214699 under ICR 201410-0920-001 · OMB 0920-0919.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Learn the Signs. Act Early. Partner Webinars	Form
Iniital survey Att1 InitialSurvey Edited Dec 2 2014 - DG+CP.docx	Form
Initial survey - screenshots Att1a Screenshots-Initial 12-3-14.docx	Form
Follow-up survey Att2 FollowUpSurvey Edited Nov 12 2014 - DG+CP.docx	Form
Follow-up survey - screenshots Att2a Screenshots-Follow up 12-3-14.docx	Form
OMB LTSAE Webinar DRAFT SUBMISSION Rev Dec 2 2014 DG+CP.docx Request for Approval	IC Document
Att3.RecruitmentEmail.docx Recruitment emails	IC Document
Att4.LTSAE Webinar Powerpoint Slides.pptx Webinar materials	IC Document

IC Title:

Agency IC Tracking Number:

15GF

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Iniital survey	Att1 InitialSurvey Edited Dec 2 2014 - DG+CP.docx	Yes	Yes	Fillable Fileable
Form	none	Initial survey - screenshots	Att1a Screenshots-Initial 12-3-14.docx	Yes	Yes	Fillable Fileable
Form	none	Follow-up survey	Att2 FollowUpSurvey Edited Nov 12 2014 - DG+CP.docx	Yes	Yes	Fillable Fileable
Form	none	Follow-up survey - screenshots	Att2a Screenshots-Follow up 12-3-14.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

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	1,200	1,200
Annual IC Time Burden (Hours)	40	40
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval	OMB LTSAE Webinar DRAFT SUBMISSION Rev Dec 2 2014 DG+CP.docx	01/21/2015
Recruitment emails	Att3.RecruitmentEmail.docx	01/21/2015
Webinar materials	Att4.LTSAE Webinar Powerpoint Slides.pptx	01/21/2015

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