Information Collection

Long Term Health Outcome Survey

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Long Term Health Outcome 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
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 %

	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

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.