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
03_IQCPEpiInfosurveytool_05-04-2017.pdf Other-Online
02_Invitation to participate IQCP 05-04-2017.docx Other-Email
01_Request for approval form IQCP05-04-2017.docx Request for Approval IC Document

Information Collection (IC) Details

IC Title:	Individualized Quality Control Plan Workbook Survey	Agency IC Tracking Number:	0920-17AQI

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
Other-Online			03_IQCPEpiInfosurveytool_05-04-2017.pdf		Yes	Yes	Fillable Fileable
Other-Email			02_Invitation to participate IQCP 05-04-2017.docx		Yes	Yes	Printable Only

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: 100 %

	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
Request for Approval	01_Request for approval form IQCP05-04-2017.docx	06/15/2017

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