Introductory Survey

Backyard Integrated Tick Management Project

Documents and Forms

Document Name Document Type
Introductory Survey Form
Introductory Survey Attachment E_Introductory survey.docx Form
Attachment D_Consent form.doc Consent IC Document

Information Collection (IC) Details

IC Title:	Introductory Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	none	Introductory Survey	Attachment E_Introductory survey.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 58	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	58	58
Annual IC Time Burden (Hours)	29	29
Annual IC Cost Burden (Dollars)	692	692

Documents for IC

Title	Document	Date Uploaded
Consent	Attachment D_Consent form.doc	08/03/2017

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