Information Collection

Learn the Signs. Act Early. Customization of Materials Customer Feedback Survey

IC 225377 under ICR 201410-0920-001 · OMB 0920-0919.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att1.Customized Materials Survey.docx	Other-WORD
Att3.Screen Shots of Customized Materials Survey.docx	Other-ScreenShots
Sup Sta A_LTSAE Customized Materials.docx Supporting Statement A	IC Document
Sup_Sta Part_B_for_BULK_ORDERS REVISED 8-28-16.docx Supporting Statement B	IC Document
Att2 Survey Invitation Email for Customized Materials.docx Att 2_Invitation Email	IC Document
Att6.Bulk Order IRB Non-Research Determination.pdf Request for Determination of Research Status	IC Document

IC Title:

Agency IC Tracking Number:

17OM

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
Other-WORD			Att1.Customized Materials Survey.docx		Yes	Yes	Fillable Fileable
Other-ScreenShots			Att3.Screen Shots of Customized Materials 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: 252

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	252	252
Annual IC Time Burden (Hours)	21	21
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	Sup Sta A_LTSAE Customized Materials.docx	01/26/2017
Supporting Statement B	Sup_Sta Part_B_for_BULK_ORDERS REVISED 8-28-16.docx	01/26/2017
Att 2_Invitation Email	Att2 Survey Invitation Email for Customized Materials.docx	01/26/2017
Request for Determination of Research Status	Att6.Bulk Order IRB Non-Research Determination.pdf	01/26/2017

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