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

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Data Use Agreement and Supplement for 2014 Health Center Patient Survey	Agency IC Tracking Number:

Is this a Common Form? No		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 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 %

	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

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.