Information Collection

Att. 3e_ Partner Survey & Partner Survey Screener

IC 222051 under ICR 201606-0920-014 · OMB 0920-1161.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1161 can be found here:

Documents and Forms

Document Name Document Type
Att 3e Partner Survey.docx Other-ORD
Att 3g Partner Survey Screener.docx Other-WORD
Att 4 Partner Survey Consent.docx Att. 4_Partner Survey Consent IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att. 3e_ Partner Survey & Partner Survey Screener	Agency IC Tracking Number:	16LL

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-ORD			Att 3e Partner Survey.docx		Yes	Yes	Fillable Printable
Other-WORD			Att 3g Partner Survey Screener.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att. 4_Partner Survey Consent	Att 4 Partner Survey Consent.docx	06/20/2016

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