Information Collection

Pactice- and Systems-Level Change Survey Sampling Form

IC 223977 under ICR 201610-0970-006 · OMB 0970-0495.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Pactice- and Systems-Level Change Survey Sampling Form	Form and Instruction
1 Practice and Systems Level Change Survey Sampling Form Practice and Systems Level Change Survey Sampling Form (4).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	Practice and Systems Level Change Survey Sampling Form	Practice and Systems Level Change Survey Sampling Form (4).docx		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: 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	14	14
Annual IC Time Burden (Hours)	4	4
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.