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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.