Information Collection

Web-based Survey of NCCCP and NSBT Staff and Partners

IC 226625 under ICR 201703-0920-006 · OMB 0920-1193.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1193 can be found here:

Documents and Forms

Document Name Document Type
Web-based Survey of NCCCP and NSBT Staff and Partners Form
Screen Shots of the Web-based Survey (with multiple opti Att 10f_Web Survey Screenshots-Multiple-Options-for-Q7.docx Form
Screen Shots of the Web-based Survey (with single option Att 10g_ Web Survey Screenshots-Single-Option-for-Q7.docx Form
Att 10a_ Web Survey Prenotification Email.docx Pre-notification Email for the Web-based Survey IC Document
Att 10b_Web Survey Invitation Email.docx Invitation Email for the Web-based Survey IC Document
Att 10c_Web Survey First Reminder Email.docx First Reminder Email for the Web-based Survey IC Document
Att 10d_ Web Survey Second Reminder Email.docx Second Reminder Email for the Web-based Survey IC Document
Att 10e_Web Survey Thank You Email.docx Thank-you Email for the Web-based Survey IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Web-based Survey of NCCCP and NSBT Staff and Partners	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	N/A	Screen Shots of the Web-based Survey (with multiple options)	Att 10f_Web Survey Screenshots-Multiple-Options-for-Q7.docx		Yes	Yes	Fillable Fileable
Form	N/A	Screen Shots of the Web-based Survey (with single option)	Att 10g_ Web Survey Screenshots-Single-Option-for-Q7.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 780	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	780	780
Annual IC Time Burden (Hours)	195	195
Annual IC Cost Burden (Dollars)	10,988	10,988

Documents for IC

Title	Document	Date Uploaded
Pre-notification Email for the Web-based Survey	Att 10a_ Web Survey Prenotification Email.docx	05/01/2017
Invitation Email for the Web-based Survey	Att 10b_Web Survey Invitation Email.docx	05/01/2017
First Reminder Email for the Web-based Survey	Att 10c_Web Survey First Reminder Email.docx	05/01/2017
Second Reminder Email for the Web-based Survey	Att 10d_ Web Survey Second Reminder Email.docx	05/01/2017
Thank-you Email for the Web-based Survey	Att 10e_Web Survey Thank You Email.docx	05/01/2017

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