Information Collection

Appendix D1. HSA Survey

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form D1 Appendix D1. HSA Survey 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

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	D1				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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Appendix D2. HSA Survey Invitation Email		06/05/2020
Appendix D3. HSA Survey Reminder Email		06/05/2020
Appendix D4. HSA Survey Reminder Telephone Script		06/05/2020
Appendix D5. HSA Survey Thank-You Email		06/05/2020
Appendix D6. HSA Survey Screenshots		06/05/2020

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

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