Partner/Nominator Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0179 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Partner/Nominator Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division Form and Instruction
1 Nominator/Partner Survey Customer Satisfaction Survey_Partner_Nominator_DRAFT REVISED _02222019.docx Form and Instruction
Generic Clearance Submission Partner Interview_10292018 (1).doc Supporting Statement IC Document
OMB Cover Letter.doc Cover Letter IC Document
NewParnterEmailInvitation_rev.docx Invitation IC Document

Information Collection (IC) Details

IC Title:	Partner/Nominator Customer Satisfaction Survey for the Evidence Based Practice Center (EPC) Division	Agency IC Tracking Number:

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 and Instruction	1	Nominator/Partner Survey	Customer Satisfaction Survey_Partner_Nominator_DRAFT REVISED _02222019.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	Generic Clearance Submission Partner Interview_10292018 (1).doc	02/22/2019
Cover Letter	OMB Cover Letter.doc	02/22/2019
Invitation	NewParnterEmailInvitation_rev.docx	02/22/2019

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