Information Collection

Web Survey Instrument

IC 233534 under ICR 201810-3135-001 · OMB 3135-0141.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Web Survey Instrument	Form and Instruction
1 Our Town Evaluation Web Survey Attachment B - Web Survey Instrument_FINAL.docx	Form and Instruction
Attachment A - Communication Materials_FINAL.docx Communications Material	IC Document
Attachment C - Cognitive Testing Report_FINAL.docx Cognitive Testing Report	IC Document
Attachment D - Final Study Plan.docx Final Study Plan	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 1320.6

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	1	Our Town Evaluation Web Survey	Attachment B - Web Survey Instrument_FINAL.docx		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records

Title: Our Town Evaluation Web Survey Instrument

FR Citation: 83 FR 16402

Number of Respondents: 381

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

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	381	381
Annual IC Time Burden (Hours)	191	191
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Communications Material	Attachment A - Communication Materials_FINAL.docx	10/15/2018
Cognitive Testing Report	Attachment C - Cognitive Testing Report_FINAL.docx	10/15/2018
Final Study Plan	Attachment D - Final Study Plan.docx	10/15/2018

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