Web Survey Instrument

Our Town Program Proposed Collection

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Web Survey Instrument	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:

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 %

	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

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.