Information Collection

Consumer Feedback Survey

IC 223224 under ICR 201608-0920-015 · OMB 0920-1151.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Consumer Feedback Survey	Form
Consumer Feedback Survey Att D-6_Consumer Feedback Survey Screenshots_8-5-16.docx	Form

IC Title:

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	none	Consumer Feedback Survey	Att D-6_Consumer Feedback Survey Screenshots_8-5-16.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 283

Number of Respondents for Small Entity: 226

Affected Public: Private Sector

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

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	283	283
Annual IC Time Burden (Hours)	9	9
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.