Information Collection

Short Course Survey for Pilot

IC 218062 under ICR 201511-0925-004 · OMB 0925-0732.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0732 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Short Course Survey for Pilot	Form and Instruction
1 Short Course Survey for Pilot 4_Attachment 1_Short Course Survey for Pilot_4.17.15.docx	Form and Instruction

IC Title:

Short Course Survey for Pilot

Agency IC Tracking Number:

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
Form and Instruction	1	Short Course Survey for Pilot	4_Attachment 1_Short Course Survey for Pilot_4.17.15.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

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	300	300
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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