Information Collection

Customer Feedback on ATSDR's Coping with Stress Fact Sheet

IC 227850 under ICR 201510-0923-001 · OMB 0923-0047.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0047 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Customer Feedback on ATSDR's Coping with Stress Fact Sheet	Form and Instruction
Feedback Form and Follow-up Interview Questions Appendix A_Stress Fact Sheet Feedback Form and Interview Questions.docx	Form and Instruction
0923-0047 Gen_Clearance_Customer_Feedback_Stress_Fact_Sheet.pdf Completed Template for Agency Service Delivery Submissions	IC Document
Appendix B_ATSDR Stress Fact Sheet.pdf Coping with Stress Fact Sheet	IC Document
Appendix C_Stress Fact Sheet Supporting Materials.docx Supporting Materials (Tips) for Using the Fact Sheet	IC Document
Appendix D ATSDR RDF Stress Fact Sheet Feedback_DCHI signed OS.pdf NCEH ATSDR Human Subjects Research Determination Form	IC Document

IC Title:

Customer Feedback on ATSDR's Coping with Stress Fact Sheet

Agency IC Tracking Number:

0923-17ANY

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 and Instruction	n/a	Feedback Form and Follow-up Interview Questions	Appendix A_Stress Fact Sheet Feedback Form and Interview Questions.docx		No		Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	7	7
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Completed Template for Agency Service Delivery Submissions	0923-0047 Gen_Clearance_Customer_Feedback_Stress_Fact_Sheet.pdf	08/07/2017
Coping with Stress Fact Sheet	Appendix B_ATSDR Stress Fact Sheet.pdf	08/07/2017
Supporting Materials (Tips) for Using the Fact Sheet	Appendix C_Stress Fact Sheet Supporting Materials.docx	08/07/2017
NCEH ATSDR Human Subjects Research Determination Form	Appendix D ATSDR RDF Stress Fact Sheet Feedback_DCHI signed OS.pdf	08/07/2017

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