Pilot Survey

National Survey of Health Information and Communication

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.