Information Collection

CBO Qualtrics Survey

IC 252916 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 1 CBO Qualtrics Survey	Form and Instruction
Form 1 CBO Qualtrics Survey	Form and Instruction
1 CBOs: Qualtrics survey Appendix B_Qualtrics and DREaM CBO quarterly survey questions_Final.docx	Form and Instruction
1 CBOs: Qualtrics survey Appendix B_Qualtrics and DREaM CBO quarterly survey questions_Final.docx	Form and Instruction

IC Title:

CBO 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
Form and Instruction	1	CBOs: Qualtrics survey	Appendix B_Qualtrics and DREaM CBO quarterly survey questions_Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: National Hypertension Control Initiative - CBOs: Qualtrics survey

FR Citation: 86 FR 70510

Number of Respondents: 16

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	128	128
Annual IC Time Burden (Hours)	192	192
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.