Information Collection

PILOT Participants Follow-Up Questionnaire

IC 216618 under ICR 201505-0920-002 · OMB 0920-1064.

Documents and Forms

Document Name Document Type
PILOT Participants Follow-Up Questionnaire Form and Instruction
Follow-Up Questionnaire Att6_Follow-upQuestionnaire.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	PILOT Participants Follow-Up Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		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	None	Follow-Up Questionnaire	Att6_Follow-upQuestionnaire.docx	None	No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	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.