Information Collection

Participant Feedback Form

IC 195850 under ICR 201705-0930-003 · OMB 0930-0195.

Documents and Forms

Document Name Document Type
Form Forms in IC-1 Participant Feedback Form Form and Instruction
Forms in IC-1 Forms in IC-1 No instruments[2].doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Participant Feedback Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Forms in IC-1	Forms in IC-1	No instruments[2].doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	835	835
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.