Information Collection

Stakeholder Survey

IC 195856 under ICR 201705-0930-002 · OMB 0930-0320.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Stakeholder Survey Stakeholder Survey	Form and Instruction
Stakeholder Survey Stakeholder Survey_Wave1 Attachment 3. CABHI_Stakeholder Survey_Wave1.docx	Form and Instruction
Stakeholder Survey Stakeholder Survey_Wave2 Attachment 4. CABHI_Stakeholder Survey_Wave2.docx	Form and Instruction
Stakeholder Survey Stakeholder Survey_Wave3 Attachment 5. CABHI_Stakeholder Survey_Wave3.docx	Form and Instruction

IC Title:

Stakeholder Survey

Agency IC Tracking Number:

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	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Stakeholder Survey_Wave1	Stakeholder Survey_Wave1	Attachment 3. CABHI_Stakeholder Survey_Wave1.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Stakeholder Survey_Wave2	Stakeholder Survey_Wave2	Attachment 4. CABHI_Stakeholder Survey_Wave2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Stakeholder Survey_Wave3	Stakeholder Survey_Wave3	Attachment 5. CABHI_Stakeholder Survey_Wave3.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 780

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	Previously Approved
Annual Number of Responses for this IC	780	132	648
Annual IC Time Burden (Hours)	320	139	181
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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