Information Collection

12 Month follow-up survey of impact study participants

IC 212904 under ICR 201604-0990-002 · OMB 0990-0424.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-424 Instrument 1 - CA Followup Survey.docx	Other-survey
0990-0424 Instrument 2 - TX Followup Survey.docx	Other-survey
0990-0424 Attachment A_ Overview of the PAF Evaluation_FU.docx Overview of the PAF Evaluation	IC Document
0990-0424 Attachment B_Question by Question Source Table for the PAF Follow Up.docx Question by Question Source List for the Follow up Survey	IC Document
0990-0424 Attachment C_Sources Referenced for PAF Follow Up.docx Sources Referenced for the Follow-up Survey	IC Document
0990-0424 Attachment D_Persons Consulted.docx Persons Consulted on Instrument Development and or Analysis of the PAF Follow-up Survey	IC Document
0990-0424 Attachment E_Confidentiality Pledge PAF FU.pdf Confidential Pledge	IC Document
0990-0424 Attachment F_PAF Analysis Plan for Impact Study_FU.docx Analysis Plan	IC Document
0990-0424 Attachment G_PAF Follow up Pretest Memorandum.docx Pretest Memo	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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-survey			0990-424 Instrument 1 - CA Followup Survey.docx		Yes	Yes	Fillable Fileable
Other-survey			0990-0424 Instrument 2 - TX Followup 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: 572

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 40 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	572	572
Annual IC Time Burden (Hours)	334	334
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Overview of the PAF Evaluation	0990-0424 Attachment A_ Overview of the PAF Evaluation_FU.docx	07/21/2015
Question by Question Source List for the Follow up Survey	0990-0424 Attachment B_Question by Question Source Table for the PAF Follow Up.docx	07/21/2015
Sources Referenced for the Follow-up Survey	0990-0424 Attachment C_Sources Referenced for PAF Follow Up.docx	07/21/2015
Persons Consulted on Instrument Development and or Analysis of the PAF Follow-up Survey	0990-0424 Attachment D_Persons Consulted.docx	07/21/2015
Confidential Pledge	0990-0424 Attachment E_Confidentiality Pledge PAF FU.pdf	07/21/2015
Analysis Plan	0990-0424 Attachment F_PAF Analysis Plan for Impact Study_FU.docx	07/21/2015
Pretest Memo	0990-0424 Attachment G_PAF Follow up Pretest Memorandum.docx	07/21/2015

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