Information Collection

MD STARnet Men Living with Muscular Dystrophy Survey

IC 258572 under ICR 202302-0920-006 · OMB 0920-1405.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MD STARnet Men Living with Muscular Dystrophy Survey	Form and Instruction
Men Living with Muscular Dystrophy Survey (paper) Attachment C_MD STARnet Men Living with MD Survey.docx	Form and Instruction
Men Living with Muscular Dystrophy Survey (paper) Attachment C_MD STARnet Men Living with MD Survey.docx	Form and Instruction
Men Living with Muscular Dystrophy Survey (screen shot o Attachment C-2_Introduction to Men's Web-based Survey.docx	Form and Instruction
Men Living with Muscular Dystrophy Survey (screen shot o Attachment C-2_Introduction to Men's Web-based Survey.docx	Form and Instruction
Men Living with Muscular Dystrophy Survey (telephone int 2023 2 13 Attachment E_MD STARnet Men Living with MD Phone Script.docx	Form and Instruction
Men Living with Muscular Dystrophy Survey (telephone int 2023 2 13 Attachment E_MD STARnet Men Living with MD Phone Script.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Men Living with Muscular Dystrophy Survey (paper)	Attachment C_MD STARnet Men Living with MD Survey.docx	No		Paper Only
Form and Instruction	None	Men Living with Muscular Dystrophy Survey (screen shot of intro to the web-based form)	Attachment C-2_Introduction to Men's Web-based Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	None	Men Living with Muscular Dystrophy Survey (telephone interview)	2023 2 13 Attachment E_MD STARnet Men Living with MD Phone Script.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 538

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 60 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	538	538
Annual IC Time Burden (Hours)	135	135
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.