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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.