Information Collection

Exam Clinic Survey

IC 233700 under ICR 201804-1405-001 · OMB 1405-0193.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0193 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Exam Clinic Survey.pdf	Other-Survey: SV-2018-0008
Generic Clearance Submission Survey Template - SV-2018-0008.pdf Generic Clearance Submission Survey Template	IC Document

IC Title:

Exam Clinic Survey

Agency IC Tracking Number:

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
Other-Survey: SV-2018-0008			Exam Clinic Survey.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,080

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,080	1,080
Annual IC Time Burden (Hours)	90	90
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Clearance Submission Survey Template	Generic Clearance Submission Survey Template - SV-2018-0008.pdf	10/24/2018

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