Information Collection

PRC Indicator Survey

IC 37806 under ICR 201806-0920-012 · OMB 0920-0650.

Documents and Forms

Document Name Document Type
PRC Indicator Survey Form
PRCP Data Collection System Attachment_4 _Web-based_Data_Collection_System_Screen_Shots_121615.docx Form
0920-0650 PRC Program Web-based Data Collection System - REDCap Attachment 1 PERS V1 REDCap Year 4-5 Screenshots 2018-06-15.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	PRC Indicator Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	PRCP Data Collection System	Attachment_4 _Web-based_Data_Collection_System_Screen_Shots_121615.docx		Yes	Yes	Fillable Fileable
Form	0920-0650	PRC Program Web-based Data Collection System - REDCap	Attachment 1 PERS V1 REDCap Year 4-5 Screenshots 2018-06-15.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 26	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	26	0	26
Annual IC Time Burden (Hours)	1,066	-182	1,248
Annual IC Cost Burden (Dollars)	0	0	0

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.