Information Collection

Attachment B: Survey instrument - participant

IC 251739 under ICR 202202-0935-001 · OMB 0935-0261.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Attachment B: Survey instrument - participant	Form and Instruction
1 1,662 Attachment_B_Survey_Instrument_Participant_10-15-2021.docx	Form and Instruction
1 1,662 Attachment_B_Survey_Instrument_Participant_10-15-2021.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	1	1,662	Attachment_B_Survey_Instrument_Participant_10-15-2021.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,662

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,662	1,662
Annual IC Time Burden (Hours)	548	548
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.