Information Collection

Survey

IC 234079 under ICR 201811-0910-002 · OMB 0910-0867.

Documents and Forms

Document Name Document Type
Appendix 1 Mail survey.docx Other-Mail Survey Instrument
Appendix 2 Web Survey.docx Other-Web Survey Instrument
Appendix 3 60 Day Publication.pdf 60 day publication IC Document
Appendix 4 Weighting.docx Appendix 4 - weighting procedures IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey	Agency IC Tracking Number:	CFSAN

Is this a Common Form? No		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
Other-Mail Survey Instrument			Appendix 1 Mail survey.docx		No		Paper Only
Other-Web Survey Instrument			Appendix 2 Web Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 564	Number of Respondents for Small Entity: 463

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 65 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	564	564
Annual IC Time Burden (Hours)	564	564
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
60 day publication	Appendix 3 60 Day Publication.pdf	11/20/2018
Appendix 4 - weighting procedures	Appendix 4 Weighting.docx	11/20/2018

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