Information Collection

Att 8_Behavioral Survey

IC 218947 under ICR 201511-0920-006 · OMB 0920-1100.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1100 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 8_Phase 2 Behavioral Survey.docx	Other-WORD
Att 11.8_Screenshots_Phase 2 Behavioral Survey.pdf Att 11.8_Screenshots	IC Document

IC Title:

Att 8_Behavioral Survey

Agency IC Tracking Number:

15AEZ

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
Other-WORD			Att 8_Phase 2 Behavioral Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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	50	50
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 11.8_Screenshots	Att 11.8_Screenshots_Phase 2 Behavioral Survey.pdf	11/12/2015

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