Information Collection

Survey

IC 248417 under ICR 202107-0920-003 · OMB 0920-1359.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1359 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-21DC Survey	Form and Instruction
0920-21DC Survey Year One Attachment 7_Survey_Year 1.docx	Form and Instruction
0920-21DC Survey Year One Attachment 7_Survey_Year 1.docx	Form and Instruction
0920-21DC Survey Year Two/Three Attachment 8_Survey_Year 2 and 3.docx	Form and Instruction
0920-21DC Survey Year Two/Three Attachment 8_Survey_Year 2 and 3.docx	Form and Instruction
Attachment 10_ Screenshots of Survey_Y1.pdf Screenshots Survey Year One	IC Document
Attachment 10_ Screenshots of Survey_Y1.pdf Screenshots Survey Year One	IC Document
Attachment 11_Screenshots of Survey_Y2-3.pdf Screenshots Survey Year Two/Three	IC Document
Attachment 11_Screenshots of Survey_Y2-3.pdf Screenshots Survey Year Two/Three	IC Document

IC Title:

Survey

Agency IC Tracking Number:

0920-21DC

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 and Instruction	0920-21DC	Survey Year One	Attachment 7_Survey_Year 1.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-21DC	Survey Year Two/Three	Attachment 8_Survey_Year 2 and 3.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 480

Number of Respondents for Small Entity: 300

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	480	480
Annual IC Time Burden (Hours)	280	280
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Screenshots Survey Year One	Attachment 10_ Screenshots of Survey_Y1.pdf	07/16/2021
Screenshots Survey Year Two/Three	Attachment 11_Screenshots of Survey_Y2-3.pdf	07/16/2021

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