Information Collection

Survey Screenshots

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

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.