Information Collection

Att 4B_CDC EHDI Hearing Screening and Follow-up Survey (HSFS)

IC 226006 under ICR 201702-0920-015 · OMB 0920-0733.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CDC EHDI Hearing S Att 4B_CDC EHDI Hearing Screening and Follow-up Survey (HSFS)	Form and Instruction
CDC EHDI Hearing S CDC Att 4B_HSFS.docx	Form and Instruction
Att 7_Unclear Response Email_2016.docx Att 7_Unclear Response Email	IC Document
Att 8_Invitation to Complete Survey_2016.docx Att 8_Invitation	IC Document
Att 9_Survey Reminder Email_2016.docx Att 9_Survey Reminder Email	IC Document
Att 10_Non Response Email_2016.docx Att 10_Non-Response Email	IC Document

IC Title:

Agency IC Tracking Number:

0920-0733

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	CDC EHDI Hearing Screening and Follow-up Survey	CDC	Att 4B_HSFS.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 57

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	57	57
Annual IC Time Burden (Hours)	228	228
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 7_Unclear Response Email	Att 7_Unclear Response Email_2016.docx	03/09/2017
Att 8_Invitation	Att 8_Invitation to Complete Survey_2016.docx	03/09/2017
Att 9_Survey Reminder Email	Att 9_Survey Reminder Email_2016.docx	03/09/2017
Att 10_Non-Response Email	Att 10_Non Response Email_2016.docx	03/09/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.