Feedback Survey

Assisted Reproductive Technology (ART) Program Reporting System

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0556 can be found here:

Documents and Forms

Document Name Document Type
Feedback Survey Form
Feedback Survey Att C4. Clinic Survey.docx Form

Information Collection (IC) Details

IC Title:	Feedback Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Form	none	Feedback Survey	Att C4. Clinic 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: 335	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	335	159	176
Annual IC Time Burden (Hours)	11	5	6
Annual IC Cost Burden (Dollars)	0	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.