Information Collection

Executive Health Services Feedback Survey

IC 253189 under ICR 202203-0704-006 · OMB 0704-0553.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0553 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MAX Survey - Senior Leader Executive Health Services Satisfaction Survey_3.9.2022.pdf	Other-Survey
OnePager_Executive Health Survey_3.17.2022.docx One Pager Executive Health Services Feedback Survey	IC Document
Example of Email sent to respondents.pdf Email Sent to Respondents	IC Document

IC Title:

Executive Health Services Feedback Survey

Agency IC Tracking Number:

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
Other-Survey			MAX Survey - Senior Leader Executive Health Services Satisfaction Survey_3.9.2022.pdf		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	166	166

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
One Pager Executive Health Services Feedback Survey	OnePager_Executive Health Survey_3.17.2022.docx	05/03/2022
Email Sent to Respondents	Example of Email sent to respondents.pdf	05/03/2022

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