Information Collection

PSE Change Network Survey

IC 210389 under ICR 201510-0920-001 · OMB 0920-1016.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att F-1(Word) PSE Change Network Survey.docx	Other-WORD
Att F2_Coalition_Survey_Advance E-Mail.docx Att F2_Coalition_Survey_Advance E-Mail	IC Document
Att F3_Coalition_Survey_Recruitment E-Mail.docx Att F3_Coalition_Survey_Recruitment E-Mail	IC Document
Att F4_Coalition_Survey_Reminder E-Mail.docx Att F4_Coalition_Survey_Reminder E-Mail	IC Document
Att F5_Coalition_Survey_Thank You E-Mail.docx Att F5_Coalition_Survey_Thank You E-Mail	IC Document
Att F-1(Screen Shots) PSE Change Network Survey.pdf Att F-1_PSE Change Network Survey (Screenshots)	IC Document

IC Title:

Agency IC Tracking Number:

15BGN

Is this a Common Form? No

IC Status: Modified

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
Other-WORD			Att F-1(Word) PSE Change Network Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 87

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	87	87
Annual IC Time Burden (Hours)	29	29
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att F2_Coalition_Survey_Advance E-Mail	Att F2_Coalition_Survey_Advance E-Mail.docx	02/11/2014
Att F3_Coalition_Survey_Recruitment E-Mail	Att F3_Coalition_Survey_Recruitment E-Mail.docx	02/11/2014
Att F4_Coalition_Survey_Reminder E-Mail	Att F4_Coalition_Survey_Reminder E-Mail.docx	02/11/2014
Att F5_Coalition_Survey_Thank You E-Mail	Att F5_Coalition_Survey_Thank You E-Mail.docx	02/11/2014
Att F-1_PSE Change Network Survey (Screenshots)	Att F-1(Screen Shots) PSE Change Network Survey.pdf	10/08/2015

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