Information Collection

ICARE Dialogues Customer feedback pre- and post-session surveys (OD/OLAW)

IC 246921 under ICR 202103-0925-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 1 ICARE Dialogues Customer feedback pre- and post-session surveys (OD/OLAW) Form
1 Pre-session survey part 1_pre-session survey instrument.pdf Form
1 Pre-session survey part 1_pre-session survey instrument.pdf Form
2 Pre-session Demographics survey Pre Session Demographics instrument.docx Form
2 Pre-session Demographics survey Pre Session Demographics instrument.docx Form
3 Part 2 Post-session survey screenshot part 2_post-session survey instrument.pdf Form
3 Part 2 Post-session survey screenshot part 2_post-session survey instrument.pdf Form
Revised ICARE Dialogues fast track -additional demographics questions FINAL (2).docx ICARE Dialogues Customer feedback pre- and post-session surveys IC Document
Revised ICARE Dialogues fast track -additional demographics questions FINAL (2).docx ICARE Dialogues Customer feedback pre- and post-session surveys IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	ICARE Dialogues Customer feedback pre- and post-session surveys (OD/OLAW)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Pre-session survey	part 1_pre-session survey instrument.pdf	Yes	Yes	Fillable Fileable
Form	2	Pre-session Demographics survey	Pre Session Demographics instrument.docx	Yes	Yes	Fillable Fileable
Form	3	Part 2 Post-session survey screenshot	part 2_post-session survey instrument.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	70	70
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
ICARE Dialogues Customer feedback pre- and post-session surveys	Revised ICARE Dialogues fast track -additional demographics questions FINAL (2).docx	04/20/2021

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