Information Collection

Coffee Zone Survey

IC 264442 under ICR 202204-0925-004 · OMB 0925-0668.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0668 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Survey Coffee Zone Survey	Form
1 Survey Coffee Zone Survey Screenshots.docx	Form
0925-0668 Template Coffee Zone.docx Template	IC Document
Coffee Zone survey email_final.docx Email Correspondence	IC Document

IC Title:

Coffee Zone 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
Form	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 220

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	660	660
Annual IC Time Burden (Hours)	110	110
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Template		01/19/2024
Email Correspondence		01/19/2024

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

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