Form 9017

Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys

2021 Virtual JMI Survey Monkey Registration_7.01.21

Health Promotion Disease Prevention Activities Registration

OMB: 0917-0036

Document [pdf]
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Page 1: Participant must read and select “yes” or “no” to continue. A “yes” selection will move the participant to the
next question. A participant that selects “no,” the system will end their registration.

2. Participant will type what community or city he/she currently lives:

3. Participant’s Contact Information:

4. Gender

5. Age group

6.

7. Participant selects race distance:

8. Adults can register up to three children under 18yrs. old:

Physical Activity and COVID-19 questions (voluntary):


File Typeapplication/pdf
File Modified2021-07-01
File Created2021-07-01

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