Information Collection

CHC Qualtrics Survey

IC 252914 under ICR 202301-0990-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.