Information Collection

CHC Qualtrics Survey

IC 252914 under ICR 202208-0990-005 · OMB 0990-0482.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0482 can be found here:

Documents and Forms

Document Name Document Type
Appendix A_Qualtrics and DREaM CHC quarterly survey questions_Final.docx Other-instruction and form
Appendix A_Qualtrics and DREaM CHC quarterly survey questions_Final.docx Other-instruction and form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CHC Qualtrics Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 1320.8(d)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-instruction and form			Appendix A_Qualtrics and DREaM CHC quarterly survey questions_Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: CHCs: Qualtrics survey	FR Citation: 86 FR 70510

Number of Respondents: 350	Number of Respondents for Small Entity: 2

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,800	2,800
Annual IC Time Burden (Hours)	1,050	1,050
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.