Information Collection

Survey Screenshots

IC 221514 under ICR 201605-0925-002 · OMB 0925-0745.

Documents and Forms

Document Name Document Type
Form 1 Survey Screenshots Form and Instruction
1 Survey Screenshots Attachment 4-Survey Screenshots.pdf Form and Instruction
Attachment 3-Paper Survey.doc Paper Survey IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey Screenshots	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Survey Screenshots	Attachment 4-Survey Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Paper Survey	Attachment 3-Paper Survey.doc	05/17/2016

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