Information Collection

Setting Demographics Survey (Appendix A)

IC 253040 under ICR 202204-0935-001 · OMB 0935-0262.

Documents and Forms

Document Name Document Type
Form 1 Setting Demographics Survey (Appendix A) Form and Instruction
1 Setting Demographics Survey (Appendix A) Appendix A_TS Dx TAT_1.4.22.docx Form and Instruction
1 Setting Demographics Survey (Appendix A) Appendix A_TS Dx TAT_1.4.22.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Setting Demographics Survey (Appendix A)	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	Setting Demographics Survey (Appendix A)	Appendix A_TS Dx TAT_1.4.22.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9	9
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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