Information Collection

Exit Survey Part 2 Feedback Survey

IC 236241 under ICR 201905-0925-005 · OMB 0925-0762.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0762 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Exit Survey Part 2 Feedback Survey	Form and Instruction
3 Exit Survey Part 2 Feedback Survey Att 2b-Exit Survey Part 2 - Feedback Survey-REV-3.11.19.pdf	Form and Instruction

IC Title:

Exit Survey Part 2 Feedback Survey

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 and Instruction	3	Exit Survey Part 2 Feedback Survey	Att 2b-Exit Survey Part 2 - Feedback Survey-REV-3.11.19.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: #09â25â0014, âClinical Research; Student Records, HHS/PHS/NIH/OD/OIR/OE

FR Citation: 67 FR 60742

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	500	500
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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