Information Collection

Att 3a_Mail-In or Web-based Questionnaire

IC 242266 under ICR 202006-0920-008 · OMB 0920-1314.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920- Mail-in Questionnaire Att 3a_Mail-In or Web-based Questionnaire	Form and Instruction
0920- Mail-in Questionnaire OCS Att 3a mail-in questionnaire Final.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-19BHM

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	0920-	Mail-in Questionnaire	OCS Att 3a mail-in questionnaire Final.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	0	0

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.