Information Collection

User Surveys for In-Home Drug Deactivation System -Private (NIDA)

IC 217619 under ICR 201503-0925-007 · OMB 0925-0655.

Documents and Forms

Document Name Document Type
Form 1 User Surveys for In-Home Drug Deactivation System -Private (NIDA) Form and Instruction
1 Home User Survey Home User Survey - Screenshot 06192015.pdf Form and Instruction
2 Provider Survey Providers Survey - Screenshot 06192015.pdf Form and Instruction
2015 Fast Track Template - Physicians - 0728015.doc Fast Track Submission Form IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	User Surveys for In-Home Drug Deactivation System -Private (NIDA)	Agency IC Tracking Number:

IC Status: New

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 and Instruction	1	Home User Survey	Home User Survey - Screenshot 06192015.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	2	Provider Survey	Providers Survey - Screenshot 06192015.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Fast Track Submission Form	2015 Fast Track Template - Physicians - 0728015.doc	08/05/2015

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