Information Collection

Pilot Survey

IC 224063 under ICR 201704-0910-010 · OMB 0910-0828.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of instruments
Document Type	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey	Yes	Yes	Fillable Fileable
Other-Survey Landing page	Yes	Yes	Fillable Fileable
Other-Survey Contact Letter	Yes	Yes	Fillable Fileable
Other-Survey Contact Postcard	Yes	Yes	Fillable Fileable
Other-Survey Contact Letter 2	Yes	Yes	Fillable Fileable
Other-Survey Contact Letter 3	Yes	Yes	Fillable Fileable
Other-Survey Contact Postcard 2	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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
OMB Justification Memo		04/20/2017

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

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