Information Collection

Change Readiness Survey

IC 227960 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⚠️ Notice: This information collection may be referencing outdated material.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 Change Readiness Survey	Form
1 Change Readiness Survey ChangeReadinessSurvey_FINAL_2017-08-17.docx	Form
OMB Form_6700B_ChangeReadinessSurvey_2017-08-17.docx Change Readiness Survey Fast track	IC Document

IC Title:

Change Readiness 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	1	Change Readiness Survey	ChangeReadinessSurvey_FINAL_2017-08-17.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

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	300	300
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Change Readiness Survey Fast track	OMB Form_6700B_ChangeReadinessSurvey_2017-08-17.docx	08/18/2017

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