Information Collection

In-depth Interview with Selected Respondents to the Web-based Survey

IC 226627 under ICR 202004-0920-020 · OMB 0920-1193.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
In-depth Interview with Selected Respondents to the Web-based Survey	Form and Instruction
In-Depth Interview Guide Att 11b_In depth Interview Guide.docx	Form and Instruction
Att 11a_Indepth Interview Introductory_Recruitment Email.docx Recruitment Email for In-depth Interviews	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	N/A	In-Depth Interview Guide	Att 11b_In depth Interview Guide.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-5	5
Annual IC Time Burden (Hours)	-3	3
Annual IC Cost Burden (Dollars)	-141	141

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Recruitment Email for In-depth Interviews	Att 11a_Indepth Interview Introductory_Recruitment Email.docx	05/01/2017

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