Information Collection

Web-based Grantee Survey

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

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
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 %

table that charts list of burden
	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

table that charts IC Documents
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.