Information Collection

Attachment B: Survey instrument - participant

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Attachment B: Survey instrument - participant	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.