Information Collection

Questionnaire

IC 245946 under ICR 202102-0920-012 · OMB 0920-1339.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Questionnaire	Form
Evaluation of VT Prevention Practices Att. 3 Screenshots of questionnaire revised.pdf	Form
Evaluation of VT Prevention Practices Att. 3 Screenshots of questionnaire revised.pdf	Form
Att. 4 PDF of questionnaire revised.pdf Questionnaire - word	IC Document
Att. 4 PDF of questionnaire revised.pdf Questionnaire - word	IC Document

IC Title:

Questionnaire

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	none	Evaluation of VT Prevention Practices	Att. 3 Screenshots of questionnaire revised.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 384

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	384	384
Annual IC Time Burden (Hours)	384	384
Annual IC Cost Burden (Dollars)	18,643	18,643

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Questionnaire - word	Att. 4 PDF of questionnaire revised.pdf	02/23/2021

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