Information Collection

Pretest

IC 214033 under ICR 201411-0910-015 · OMB 0910-0784.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0784 can be found here:

Documents and Forms

Document Name Document Type
SURVEY QUESTIONNAIRE 10-28-14.docx Other- Questionnaire

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pretest	Agency IC Tracking Number:

Is this a Common Form? No		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
Other- Questionnaire			SURVEY QUESTIONNAIRE 10-28-14.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: 1,100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,100	1,100
Annual IC Time Burden (Hours)	550	550
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.