Information Collection

Data Use Agreement and Supplement for 2014 Health Center Patient Survey

IC 224072 under ICR 201610-0906-001 · OMB 0906-0027.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Data Use Agreement and Supplement for 2014 Health Center Patient Survey	Form and Instruction
1 DUA DUA.docx	Form and Instruction
1 DUA Supplement DUA Supplement.docx	Form and Instruction

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 and Instruction	1	DUA	DUA.docx		Yes	Yes	Fillable Fileable
Form and Instruction	1	DUA Supplement	DUA Supplement.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: 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	40	40
Annual IC Time Burden (Hours)	30	30
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.