Individualized Quality Control Plan Workbook Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Documents and Forms

Document Name Document Type
Form 0920-0974 Individualized Quality Control Plan Workbook Survey Form
02_Invitation to participate IQCP 01-24-2017.docx Instruction
0920-0974 03_Screen shots of IQCP Workbook Survey 01-19-2017 03_Screen shots of IQCP Workbook Survey 01-19-2017.pdf Form
01_Request for approval form IQCP 01-24-2017.docx 01_Request for approval form IQCP 01-24-2017 IC Document

Information Collection (IC) Details

IC Title:	Individualized Quality Control Plan Workbook Survey	Agency IC Tracking Number:	17NR

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	0920-0974	03_Screen shots of IQCP Workbook Survey 01-19-2017	03_Screen shots of IQCP Workbook Survey 01-19-2017.pdf		Yes	Yes	Fillable Printable
Instruction			02_Invitation to participate IQCP 01-24-2017.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	84	84
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
01_Request for approval form IQCP 01-24-2017	01_Request for approval form IQCP 01-24-2017.docx	01/25/2017

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