Information Collection

Non-response Follow-back Survey

IC 220189 under ICR 201605-0925-011 · OMB 0925-0739.

Documents and Forms

Document Name Document Type
Form 3 Non-response Follow-back Survey Form and Instruction
3 Attachment E Nonresponse Followback Survey Attach E Nonresponse Followback Survey.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Non-response Follow-back Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	3	Attachment E Nonresponse Followback Survey	Attach E Nonresponse Followback 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: 40	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.