Information Collection

Pilot Survey

IC 224063 under ICR 201610-0910-006 · OMB 0910-0828.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0828 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix A Survey.pdf	Other-Survey
Appendix B Landing Page Text.pdf	Other-Survey Landing page
Appendix C Contact 1_Letter.pdf	Other-Survey Contact Letter
Appendix D Contact 2_Postcard.pdf	Other-Survey Contact Postcard
Appendix E Contact 3_Letter.pdf	Other-Survey Contact Letter 2
Appendix F Contact 4_Letter.pdf	Other-Survey Contact Letter 3
Appendix G Contact 5_Postcard.pdf	Other-Survey Contact Postcard 2

IC Title:

Pilot Survey

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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey Landing page	Appendix B Landing Page Text.pdf	Yes	Yes	Fillable Fileable
Other-Survey	Appendix A Survey.pdf	Yes	Yes	Fillable Fileable
Other-Survey Contact Letter	Appendix C Contact 1_Letter.pdf	Yes	Yes	Fillable Fileable
Other-Survey Contact Postcard	Appendix D Contact 2_Postcard.pdf	Yes	Yes	Fillable Fileable
Other-Survey Contact Letter 2	Appendix E Contact 3_Letter.pdf	Yes	Yes	Fillable Fileable
Other-Survey Contact Letter 3	Appendix F Contact 4_Letter.pdf	Yes	Yes	Fillable Fileable
Other-Survey Contact Postcard 2	Appendix G Contact 5_Postcard.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	100	100
Annual IC Time Burden (Hours)	39	39
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.