Information Collection

Proxy Survey Web Mode

IC 228541 under ICR 201709-0920-009 · OMB 0920-1220.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Proxy Survey Web Mode	Form and Instruction
Proxy Survey Web Mode Att B-13. Falls Proxy Screenshots.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-17HO

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Proxy Survey Web Mode	Att B-13. Falls Proxy Screenshots.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 252

Number of Respondents: 57

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	228	228
Annual IC Time Burden (Hours)	11	11
Annual IC Cost Burden (Dollars)	255	255

Documents for IC

table that charts IC Documents
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.