Information Collection

Survey

IC 241655 under ICR 202002-0990-001 · OMB 0990-0474.

Documents and Forms

Document Name Document Type
3. Attachment A - Survey 7-23-2020 CLEAN.docx Other-survey

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	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
Other-survey			3. Attachment A - Survey 7-23-2020 CLEAN.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 87	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	87	87
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	793	793

Documents for IC

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.