Information Collection

Survey

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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.