Information Collection

2018 NPIN Web-based Survey

IC 231322 under ICR 201705-0920-017 · OMB 0920-1027.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.