Information Collection

Web-based Grantee Survey

IC 233842 under ICR 201811-0920-001 · OMB 0920-1250.

Documents and Forms

Document Name Document Type
Web-based Grantee Survey Form
Grantee Survey Att 3a_ Web-based Grantee Survey.docx Form
Grantee Survey - screenshots Att 3b_ Web-based Grantee Survey Screenshots.docx Form
Att 3e_Introductory Email for Web-based Survey Participants.docx Introductory Email IC Document
Att 3f_Reminder Email for Web-based Survey Participants.docx Reminder Email IC Document
Att 3g_Follow-up Reminder Email for Web-based Survey Participants.docx Follow-up- Email IC Document
Att 3h_Thank You Email for Web-based Survey Participants.docx Thank you Email IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Web-based Grantee Survey	Agency IC Tracking Number:

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
Form	none	Grantee Survey	Att 3a_ Web-based Grantee Survey.docx		Yes	Yes	Fillable Fileable
Form	none	Grantee Survey - screenshots	Att 3b_ Web-based Grantee Survey Screenshots.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	8	8
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	79	79

Documents for IC

Title	Document	Date Uploaded
Introductory Email	Att 3e_Introductory Email for Web-based Survey Participants.docx	11/01/2018
Reminder Email	Att 3f_Reminder Email for Web-based Survey Participants.docx	11/01/2018
Follow-up- Email	Att 3g_Follow-up Reminder Email for Web-based Survey Participants.docx	11/01/2018
Thank you Email	Att 3h_Thank You Email for Web-based Survey Participants.docx	11/01/2018

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