Information Collection

Long Term Health Outcome Survey

IC 218647 under ICR 201510-0420-002 · OMB 0420-0557.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2155 Long Term Health Outcome Survey	Form
2155 RPCV Long Term Health Outcomes Survey LTC form_Survey v2.pdf	Form
Long Term Health Survey_Supporting Statement_v2.docx Long Term Health Survey_Supporting Statement_v2	IC Document
_Lonh Term Healh Survey_Protocol.docx _Lonh Term Healh Survey_Protocol	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	2155	RPCV Long Term Health Outcomes Survey	LTC form_Survey v2.pdf		Yes	Yes	Fillable Fileable

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11,196

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	11,196	11,196
Annual IC Time Burden (Hours)	2,799	2,799
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Long Term Health Survey_Supporting Statement_v2	Long Term Health Survey_Supporting Statement_v2.docx	05/25/2016
_Lonh Term Healh Survey_Protocol	_Lonh Term Healh Survey_Protocol.docx	05/25/2016

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