Information Collection

Exit survey Part 1

IC 249046 under ICR 202108-0925-003 · OMB 0925-0772.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0772 can be found here:

Documents and Forms

Document Name Document Type
Form 2 Exit survey Part 1 Form and Instruction
2 Exit survey Part 1 attachment 2 - Exit Survey Part 1 Screenshots.pdf Form and Instruction
2 Exit survey Part 1 Data Collection Instrument - Exit Survey Part 1- Revised.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Exit survey Part 1	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	2	Exit survey Part 1	Data Collection Instrument - Exit Survey Part 1- Revised.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09â25â0014, âClinical Research; Student Records, HHS/PHS/NIH/OD/OIR/OE.â	FR Citation: 67 FR 67042

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	13	13
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.