Information Collection

Pilot Survey

IC 224063 under ICR 201707-0910-015 · OMB 0910-0828.

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: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey	Appendix A Survey.pdf	Yes	Yes	Fillable Fileable
Other-Survey Landing page	Appendix B Landing Page Text.pdf	Yes	Yes	Fillable Fileable
Other-Survey Contact Letter	Appendix C Contact 1_Letter.pdf	Yes	Yes	Fillable Fileable
Other-Survey Contact Postcard	Appendix D Contact 2_Postcard.pdf	Yes	Yes	Fillable Fileable
Other-Survey Contact Letter 2	Appendix E Contact 3_Letter.pdf	Yes	Yes	Fillable Fileable
Other-Survey Contact Letter 3	Appendix F Contact 4_Letter.pdf	Yes	Yes	Fillable Fileable
Other-Survey Contact Postcard 2	Appendix G Contact 5_Postcard.pdf	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	Previously Approved
Annual Number of Responses for this IC	118	118
Annual IC Time Burden (Hours)	52	52
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OMB Justification Memo	0828 83C Justification Memorandum 4-20-2017.docx	04/20/2017

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