Information Collection

Web-based Survey of NCCCP Coalition Members and NCCCP Partners

IC 242185 under ICR 202004-0920-020 · OMB 0920-1193.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Web-based Survey of NCCCP Coalition Members and NCCCP Partners	Form and Instruction
Att 5d. Web-based survey (Word Format).docx	Other-Word version of survey content
Web-based Survey (screenshots) Att 5e. Web-based survey (screenshots).docx	Form and Instruction

IC Title:

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	n/a	Web-based Survey (screenshots)	Att 5e. Web-based survey (screenshots).docx		Yes	Yes	Fillable Fileable
Other-Word version of survey content to facilitate content review			Att 5d. Web-based survey (Word Format).docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 88

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	88	88
Annual IC Time Burden (Hours)	22	22
Annual IC Cost Burden (Dollars)	1,306	1,306

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.