Information Collection

Survey

IC 242164 under ICR 202110-0920-013 · OMB 0920-1308.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1308 can be found here:

Documents and Forms

Document Name Document Type
Survey Form
Survey SSA Attachment 3 Appendix 2 Instrument 27Apr2020.docx Form
Survey SSA Attachment 3 Appendix 2 Instrument 27Apr2020.docx Form
0920-1308 Validated Survey Instrument SSA Attachment 3 Appendix 2 Instrument 08Oct21 Clean.pdf Form
0920-1308 Validated Survey Instrument SSA Attachment 3 Appendix 2 Instrument 08Oct21 Clean.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	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	none	Survey	SSA Attachment 3 Appendix 2 Instrument 27Apr2020.docx		Yes	Yes	Fillable Fileable
Form	0920-1308	Validated Survey Instrument	SSA Attachment 3 Appendix 2 Instrument 08Oct21 Clean.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: 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	250	0	250
Annual IC Time Burden (Hours)	83	-84	167
Annual IC Cost Burden (Dollars)	12,095	0	12,095

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.