Information Collection

NCCIH Customer Service Data Collection

IC 217316 under ICR 201501-0925-004 · OMB 0925-0648.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0648 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 NCCIH Customer Service Data Collection	Form and Instruction
1 Telephone Survey APPENDIX A Survey Instrument- Telephone_FINAL.doc	Form and Instruction
2 Email Survey APPENDIX C Survey Instrument Email_FINAL.doc	Form and Instruction
Fast track Template_OMB Control Number 09250648 NCCIH survey 2015_draft_submission v2.doc Fast Track Submission Form	IC Document
Appendix B Caller Anonymity_FINAL.doc Caller Anonymity	IC Document

IC Title:

NCCIH Customer Service Data Collection

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	Telephone Survey	APPENDIX A Survey Instrument- Telephone_FINAL.doc		No		Paper Only
Form and Instruction	2	Email Survey	APPENDIX C Survey Instrument Email_FINAL.doc		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 412

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	412	412
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast Track Submission Form	Fast track Template_OMB Control Number 09250648 NCCIH survey 2015_draft_submission v2.doc	07/02/2015
Caller Anonymity	Appendix B Caller Anonymity_FINAL.doc	07/02/2015

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