2018 NPIN Web-based Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCHHSTP)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1027 can be found here:

Documents and Forms

Document Name Document Type
2018 NPIN Web-based Survey Form
NPIN Survey Screener Att1 NPIN Evaluation Screener.docx Form
NPIN Survey - word Att3 2018-NPIN Eval Survey.docx Form
NPIN Survey - screenshots Att3 NPIN Survey Screen shots.pdf Form
2018 NPIN EvaluationSurvey_FastTrack ShortForm-05-03-2018.docx Request for Approval IC Document
Att2 NPIN Eval Survey Consent Form-5-3-2018.docx Consent IC Document
Att4 NPIN Sampling Frame Final.docx Sampling Frame IC Document

Information Collection (IC) Details

IC Title:	2018 NPIN Web-based Survey	Agency IC Tracking Number:	0920-1027-18ACL

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	NPIN Survey - word	Att3 2018-NPIN Eval Survey.docx	Yes	Yes	Fillable Fileable
Form	none	NPIN Survey - screenshots	Att3 NPIN Survey Screen shots.pdf	Yes	Yes	Fillable Fileable
Form	none	NPIN Survey Screener	Att1 NPIN Evaluation Screener.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,120	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	12,120	12,120
Annual IC Time Burden (Hours)	260	260
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval	2018 NPIN EvaluationSurvey_FastTrack ShortForm-05-03-2018.docx	05/03/2018
Consent	Att2 NPIN Eval Survey Consent Form-5-3-2018.docx	05/03/2018
Sampling Frame	Att4 NPIN Sampling Frame Final.docx	05/03/2018

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