Information Collection

Follow-up Survey

IC 238161 under ICR 202202-0920-003 · OMB 0920-1281.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Follow-up Survey	Form and Instruction
Follow up survey Att. 2 - Follow up patient survey (1).docx	Form and Instruction
Follow up survey Att. 2 - Follow up patient survey (1).docx	Form and Instruction

IC Title:

Follow-up Survey

Agency IC Tracking Number:

0920-19ARD

Is this a Common Form? No

IC Status: Unchanged

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	none	Follow up survey	Att. 2 - Follow up patient survey (1).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 896

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,688	2,688
Annual IC Time Burden (Hours)	672	672
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.