Information Collection

Benchmark & Follow-Up Web Surveys – Consumer Audience

IC 247688 under ICR 202111-0925-006 · OMB 0925-0769.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 6 Benchmark & Follow-Up Web Surveys – Consumer Audience	Form
6 Custom Web Survey with Consumer and Provider Paths Attachment 6 - Custom Web Survey with Consumer and Provider Paths_clean 110821.docx	Form
6 Custom Web Survey with Consumer and Provider Paths Attachment 6 - Custom Web Survey with Consumer and Provider Paths_clean 110821.docx	Form
Federal COVID Response 0925-0769 - Consumer Suppl Materials.pptx Federal COVID Response Consumer Suppl Material	IC Document
Federal COVID Response 0925-0769 - Consumer Suppl Materials.pptx Federal COVID Response Consumer Suppl Material	IC Document

IC Title:

Benchmark & Follow-Up Web Surveys â Consumer Audience

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	6	Custom Web Survey with Consumer and Provider Paths	Attachment 6 - Custom Web Survey with Consumer and Provider Paths_clean 110821.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

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	Previously Approved
Annual Number of Responses for this IC	10,000	10,000
Annual IC Time Burden (Hours)	2,500	2,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Federal COVID Response Consumer Suppl Material	Federal COVID Response 0925-0769 - Consumer Suppl Materials.pptx	11/23/2021

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