Information Collection

Survey

IC 242164 under ICR 202006-0920-004 · OMB 0920-1308.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1308 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Survey	Form
Survey SSA Attachment 3 Appendix 2 Instrument 27Apr2020.docx	Form

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Survey	SSA Attachment 3 Appendix 2 Instrument 27Apr2020.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

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	250	250
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	12,095	12,095

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.