Coalition participants, and other community members online survey

Evaluation of the Office on Women's Health (OWH) Coalition for a Healthier Community (CHC) Initiative

Documents and Forms

Document Name Document Type
0990-CHC_Coalition Participants and Other Community Members Online Survey.doc Other-survey

Information Collection (IC) Details

IC Title:	Coalition participants, and other community members online survey	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
Other-survey			0990-CHC_Coalition Participants and Other Community Members Online Survey.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 510	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	510	510
Annual IC Time Burden (Hours)	170	170
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.