Information Collection

Same Day Services Survey

IC 242973 under ICR 202003-2900-011 · OMB 2900-0876.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0876 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2900-08767-S1 Same Day Services Survey	Form and Instruction
2900-08767-S1 Same Day Services Survey Questions Same Day Services Survey Wireframes (001).pdf	Form and Instruction
A-11 Fast-Track Clearance Request Template_Same Day Svcs_(004).pdf Requirements Document	IC Document
Service Level Measurement -Same Day Services (002).docx Statistical Sample Plan	IC Document

IC Title:

Same Day Services Survey

Agency IC Tracking Number:

2900-0876-S

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	2900-08767-S1	Same Day Services Survey Questions	Same Day Services Survey Wireframes (001).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 238,848

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	238,848	238,848
Annual IC Time Burden (Hours)	19,904	19,904
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Requirements Document	A-11 Fast-Track Clearance Request Template_Same Day Svcs_(004).pdf	08/03/2020
Statistical Sample Plan	Service Level Measurement -Same Day Services (002).docx	08/03/2020

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