Information Collection

CureTB Partner Feedback (at time of patient referral)

IC 252223 under ICR 202203-0920-003 · OMB 0920-1186.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1186 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CureTB Partner Feedback (at time of patient referral)	Form and Instruction
Attachment A1.a. – Supplemental CureTB Program Partner Satisfaction Assessment Questionnaire 1.pdf	Other-Questionnaire annotated with s
Attachment A1.a. – Supplemental CureTB Program Partner Satisfaction Assessment Questionnaire 1.pdf	Other-Questionnaire annotated with s
CureTB Partner Feedback Attachment A1.b. Questionnaire 1 - Online Survey Preview-no skip logic.pdf	Form and Instruction
CureTB Partner Feedback Attachment A1.b. Questionnaire 1 - Online Survey Preview-no skip logic.pdf	Form and Instruction

IC Title:

CureTB Partner Feedback (at time of patient referral)

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	n/a	CureTB Partner Feedback	Attachment A1.b. Questionnaire 1 - Online Survey Preview-no skip logic.pdf		Yes	Yes	Fillable Fileable
Other-Questionnaire annotated with skip logic			Attachment A1.a. â Supplemental CureTB Program Partner Satisfaction Assessment Questionnaire 1.pdf		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	100	100
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	743	743

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.