Information Collection

Family-to-Family Health Information Center Feedback Surveys

IC 234425 under ICR 202201-0906-001 · OMB 0906-0040.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Family-to-Family Health Information Center Feedback Surveys	Form and Instruction
2 F2FHIC_Feedback Surveys Final clean.docx FORM - F2FHIC_Feedback Surveys Final clean.docx	Form and Instruction
2 F2FHIC_Feedback Surveys Final clean.docx FORM - F2FHIC_Feedback Surveys Final clean.docx	Form and Instruction
FeedbackSurvey_GrantRecipient_Instructions.docx Feeback Survey Grant Recepient Instructions	IC Document
FeedbackSurvey_GrantRecipient_Instructions.docx Feeback Survey Grant Recepient Instructions	IC Document

IC Title:

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 and Instruction	2	F2FHIC_Feedback Surveys Final clean.docx	FORM - F2FHIC_Feedback Surveys Final clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,000

Number of Respondents for Small Entity: 1,000

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4,000	2,853	1,147
Annual IC Time Burden (Hours)	600	428	172
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Feeback Survey Grant Recepient Instructions	FeedbackSurvey_GrantRecipient_Instructions.docx	12/06/2018

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