Pilot Survey

National Survey of Health Information and Communication

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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
0828 83C Justification Memorandum 4-20-2017.docx OMB Justification Memo IC Document

Information Collection (IC) Details

IC Title:	Pilot Survey	Agency IC Tracking Number:	CDER

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
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
Other-Survey	Appendix A Survey.pdf	Yes	Yes	Fillable Fileable
Other-Survey Landing page	Appendix B Landing Page Text.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

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 118	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	118	18	100
Annual IC Time Burden (Hours)	52	13	39
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
OMB Justification Memo	0828 83C Justification Memorandum 4-20-2017.docx	04/20/2017

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