Information Collection

User Survey for In-Home Drug Deactivation System - Individuals and Households

IC 217778 under ICR 201503-0925-007 · OMB 0925-0655.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 User Survey for In-Home Drug Deactivation System - Individuals and Households	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 - Households- 0728015.doc Fast Track Submission Form	IC Document

IC Title:

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 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: 2,000

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	2,000	2,000
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast Track Submission Form	2015 Fast Track Template - Households- 0728015.doc	08/05/2015

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