Feedback Survey

Assisted Reproductive Technology (ART) Program Reporting System

Documents and Forms

Document Name Document Type
Feedback Survey Form and Instruction
NASS Clinic Feedback Survey Att C4. Clinic Feedback Survey.pdf Form and Instruction
NASS Clinic Feedback Survey Att C4. Clinic Feedback Survey.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Feedback Survey	Agency IC Tracking Number:

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
Form and Instruction	n/a	NASS Clinic Feedback Survey	Att C4. Clinic Feedback Survey.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 255	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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	255	-93	348
Annual IC Time Burden (Hours)	9	-3	12
Annual IC Cost Burden (Dollars)	391	391	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.