Information Collection

Follow-up Survey

IC 219539 under ICR 201601-0920-007 · OMB 0920-1116.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Follow-up Survey	Form
Follow-up Survey Att3C FollowupSurvey.docx	Form

IC Title:

Follow-up Survey

Agency IC Tracking Number:

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
Form	none	Follow-up Survey	Att3C FollowupSurvey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 298

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	1,192	1,192
Annual IC Time Burden (Hours)	596	596
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.