Information Collection

Client Survey (Participant)

IC 257786 under ICR 202212-0920-002 · OMB 0920-1403.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920- Client Survey (Participant)	Form
0920- Client Survey Att 4_Participant Survey.docx	Form
0920- Client Survey Att 4_Participant Survey.docx	Form
Att 4a_Participant Survey Screenshots.docx Client Survey (Participant)	IC Document
Att 4a_Participant Survey Screenshots.docx Client Survey (Participant)	IC Document

IC Title:

Agency IC Tracking Number:

0920-22IJ

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	0920-	Client Survey	Att 4_Participant Survey.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Client Survey (Participant)	Att 4a_Participant Survey Screenshots.docx	01/06/2023

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