Information Collection

Final Survey

IC 227804 under ICR 201708-0920-006 · OMB 0920-1203.

Documents and Forms

Document Name Document Type
Final Survey Form
Final Survey Attachment I_Final survey.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Final 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	Final Survey	Attachment I_Final survey.doc		Yes	Yes	Fillable Fileable

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: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	58	58
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	346	346

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.