Information Collection

Att. 3e_ Partner Survey & Partner Survey Screener

IC 222051 under ICR 202012-0920-011 · OMB 0920-1161.

Documents and Forms

Document Name Document Type
Form 0920-1161 Att. 3e_ Partner Survey & Partner Survey Screener Form
0920-1161 Partner Survey Att3e_Partner Survey.docx Form
0920-1161 Patner Survey Screener Att3g_Partner Survey Screener.docx Form
Att4_Partner Survey Consent.docx Att. 4_Partner Survey Consent IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att. 3e_ Partner Survey & Partner Survey Screener	Agency IC Tracking Number:	16LL

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-1161	Partner Survey	Att3e_Partner Survey.docx		Yes	Yes	Fillable Printable
Form	0920-1161	Patner Survey Screener	Att3g_Partner Survey Screener.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att. 4_Partner Survey Consent	Att4_Partner Survey Consent.docx	02/22/2021

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