Information Collection

Prevention and Wellness Survey

IC 215718 under ICR 201503-0920-007 · OMB 0920-1079.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Prevention and Wellness Survey	Form
Survey Appendix D_AHIP Prevention and Wellness Survey_Screen Shots_FINAL_012115.doc	Form
Appendix C_AHIP Prevention and Wellness Survey_FINAL_012115.doc Survey Word Document	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	none	Survey	Appendix D_AHIP Prevention and Wellness Survey_Screen Shots_FINAL_012115.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 150

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	150	150
Annual IC Time Burden (Hours)	75	75
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey Word Document	Appendix C_AHIP Prevention and Wellness Survey_FINAL_012115.doc	03/18/2015

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