Information Collection

Att 3_Web-Based Survey

IC 223930 under ICR 202106-0920-013 · OMB 0920-1182.

Documents and Forms

Document Name Document Type
Att3-Web-based Survey.docx Other-WORD
Att3a-Web-based Survey Screenshots.docx Other-Scrteenshots

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att 3_Web-Based Survey	Agency IC Tracking Number:	0920-1182

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			Att3-Web-based Survey.docx		Yes	Yes	Fillable Fileable
Other-Scrteenshots			Att3a-Web-based Survey Screenshots.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 569	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	569	569
Annual IC Time Burden (Hours)	142	142
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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