Information Collection

Change Readiness Survey (OD)

IC 233574 under ICR 202102-0925-005 · OMB 0925-0648.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0648 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Change Readiness Survey (OD)	Form and Instruction
1 ChangeReadiness Survey screenshot 101118-Rock I_II-ChangeReadinessSurvey_Screen Shots.docx	Form and Instruction
1 ChangeReadiness Survey screenshot 101118-Rock I_II-ChangeReadinessSurvey_Screen Shots.docx	Form and Instruction
101618-BMoss-Request-ChangeReadinessSurvey.docx ChangeReadiness Survey fast track	IC Document
101618-BMoss-Request-ChangeReadinessSurvey.docx ChangeReadiness Survey fast track	IC Document

IC Title:

Change Readiness Survey (OD)

Agency IC Tracking Number:

IC Status: Unchanged

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 and Instruction	1	ChangeReadiness Survey screenshot	101118-Rock I_II-ChangeReadinessSurvey_Screen Shots.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,150

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	2,150	2,150
Annual IC Time Burden (Hours)	179	179
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ChangeReadiness Survey fast track	101618-BMoss-Request-ChangeReadinessSurvey.docx	10/16/2018

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