Information Collection

12 Month follow-up survey of impact study participants

IC 212904 under ICR 201505-0990-001 · OMB 0990-0424.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0424 can be found here:

Documents and Forms

Document Name Document Type
0990-424 Instrument 1 - CA Followup Survey.docx Other-survey
0990-0424 Instrument 2 - TX Followup Survey.docx Other-survey
0990-0424 Attachment A_ Overview of the PAF Evaluation_FU.docx Overview of the PAF Evaluation IC Document
0990-0424 Attachment B_Question by Question Source Table for the PAF Follow Up.docx Question by Question Source List for the Follow up Survey IC Document
0990-0424 Attachment C_Sources Referenced for PAF Follow Up.docx Sources Referenced for the Follow-up Survey IC Document
0990-0424 Attachment D_Persons Consulted.docx Persons Consulted on Instrument Development and or Analysis of the PAF Follow-up Survey IC Document
0990-0424 Attachment E_Confidentiality Pledge PAF FU.pdf Confidential Pledge IC Document
0990-0424 Attachment F_PAF Analysis Plan for Impact Study_FU.docx Analysis Plan IC Document
0990-0424 Attachment G_PAF Follow up Pretest Memorandum.docx Pretest Memo IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	12 Month follow-up survey of impact study participants	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-survey			0990-424 Instrument 1 - CA Followup Survey.docx		Yes	Yes	Fillable Fileable
Other-survey			0990-0424 Instrument 2 - TX Followup Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 638	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	638	637	1
Annual IC Time Burden (Hours)	372	372	0
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Overview of the PAF Evaluation	0990-0424 Attachment A_ Overview of the PAF Evaluation_FU.docx	07/21/2015
Question by Question Source List for the Follow up Survey	0990-0424 Attachment B_Question by Question Source Table for the PAF Follow Up.docx	07/21/2015
Sources Referenced for the Follow-up Survey	0990-0424 Attachment C_Sources Referenced for PAF Follow Up.docx	07/21/2015
Persons Consulted on Instrument Development and or Analysis of the PAF Follow-up Survey	0990-0424 Attachment D_Persons Consulted.docx	07/21/2015
Confidential Pledge	0990-0424 Attachment E_Confidentiality Pledge PAF FU.pdf	07/21/2015
Analysis Plan	0990-0424 Attachment F_PAF Analysis Plan for Impact Study_FU.docx	07/21/2015
Pretest Memo	0990-0424 Attachment G_PAF Follow up Pretest Memorandum.docx	07/21/2015

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