Information Collection

Online Survey Instrument

IC 192388 under ICR 201503-0920-014 · OMB 0920-0600.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0600 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Online Survey Instrument	Form
Survey Screenshots Att C Survey Instrument Web Shots.pdf	Form
Survey Instrument Changes.docx Survey Instrument Changes	IC Document

IC Title:

Online Survey Instrument

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 Screenshots	Att C Survey Instrument Web Shots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 93

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	186	186
Annual IC Time Burden (Hours)	47	47
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Survey Instrument Changes	Survey Instrument Changes.docx	11/07/2013

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