Information Collection

DSSEM Application and Interview Satisfaction Survey

IC 227714 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⚠️ Notice: This information collection may be referencing outdated material.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 DSSEM Application and Interview Satisfaction Survey	Form and Instruction
1 DSSEM Application and Interview Survey DSSEM_Application_and_Interview_Survey.docx	Form and Instruction
Fast Track for DSSEM Application and Interview Satisfaction Survey.docx Fast track for DSSEM Application and Interview Satisfaction Survey	IC Document

IC Title:

DSSEM Application and Interview 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	DSSEM Application and Interview Survey	DSSEM_Application_and_Interview_Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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	50	50
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast track for DSSEM Application and Interview Satisfaction Survey	Fast Track for DSSEM Application and Interview Satisfaction Survey.docx	07/26/2017

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