Information Collection

NICHD Safe to Sleep® Campaign High-Risk States Outreach Program Customer Satisfaction Survey

IC 214906 under ICR 201410-0925-002 · OMB 0925-0643.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0643 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 NICHD Safe to Sleep® Campaign High-Risk States Outreach Program Customer Satisfaction Survey	Form and Instruction
1 High-risk States Outreach Program Customer Satisfaction 0925-0643_High-risk States Outreach Program Customer Satisfaction Survey.docx	Form and Instruction
0925-0643_Fast Track_High-Risk States Customer Satisfaction Survey_11-26-14_FINAL-1.doc Fast-Track template High-risk States Outreach Program Customer Satisfaction Survey	IC Document

IC Title:

NICHD Safe to SleepÂ® Campaign High-Risk States Outreach Program Customer Satisfaction Survey

Agency IC Tracking Number:

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	1	High-risk States Outreach Program Customer Satisfaction Survey	0925-0643_High-risk States Outreach Program Customer Satisfaction 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: 70

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	70	70
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast-Track template High-risk States Outreach Program Customer Satisfaction Survey	0925-0643_Fast Track_High-Risk States Customer Satisfaction Survey_11-26-14_FINAL-1.doc	02/05/2015

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