Information Collection

Appendix D1. HSA Survey

IC 242180 under ICR 202006-0935-001 · OMB 0935-0255.

Documents and Forms

Document Name Document Type
Form D1 Appendix D1. HSA Survey Form
D1 Appendix D1. HSA Survey Appendix D1. HSA Survey_5-18-20.docx Form
Appendix D2. Survey Invitation Email 5-8-20.docx Appendix D2. HSA Survey Invitation Email IC Document
Appendix D3. Survey Reminder Email 5-8-20.docx Appendix D3. HSA Survey Reminder Email IC Document
Appendix D4. Survey Reminder Telephone Script.docx Appendix D4. HSA Survey Reminder Telephone Script IC Document
Appendix D5. Survey Thank You Email 5-18-20.docx Appendix D5. HSA Survey Thank-You Email IC Document
Appendix D6. HSA Survey Screenshots.docx Appendix D6. HSA Survey Screenshots IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Appendix D1. HSA Survey	Agency IC Tracking Number:

Is this a Common Form? No		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	D1	Appendix D1. HSA Survey	Appendix D1. HSA Survey_5-18-20.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 63	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	63	63
Annual IC Time Burden (Hours)	11	11
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix D2. HSA Survey Invitation Email	Appendix D2. Survey Invitation Email 5-8-20.docx	06/05/2020
Appendix D3. HSA Survey Reminder Email	Appendix D3. Survey Reminder Email 5-8-20.docx	06/05/2020
Appendix D4. HSA Survey Reminder Telephone Script	Appendix D4. Survey Reminder Telephone Script.docx	06/05/2020
Appendix D5. HSA Survey Thank-You Email	Appendix D5. Survey Thank You Email 5-18-20.docx	06/05/2020
Appendix D6. HSA Survey Screenshots	Appendix D6. HSA Survey Screenshots.docx	06/05/2020

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