Information Collection

Att. 3e_ Partner Survey & Partner Survey Screener

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.