Information Collection

HC3 Customer Feedback Form

IC 242004 under ICR 201703-0990-003 · OMB 0990-0459.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0459 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-0459 HC3 Customer Feedback Form 05_28.pdf	Other-survey
0990-0459 HC3 Fast Track Generic IC Memo Justification05_21_20.docx Memo	IC Document

IC Title:

HC3 Customer Feedback Form

Agency IC Tracking Number:

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
Other-survey			0990-0459 HC3 Customer Feedback Form 05_28.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	200	200
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Memo	0990-0459 HC3 Fast Track Generic IC Memo Justification05_21_20.docx	05/28/2020

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