Information Collection

Survey

IC 242164 under ICR 202306-0920-007 · OMB 0920-1308.

Documents and Forms

Document Name Document Type
Survey Form and Instruction
Survey Attachment 3a Appendix 1_SCORE UC Option Period_Survey Instrument_final.docx Form and Instruction
Survey Attachment 3a Appendix 1_SCORE UC Option Period_Survey Instrument_final.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Survey	Attachment 3a Appendix 1_SCORE UC Option Period_Survey Instrument_final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	250	0	250
Annual IC Time Burden (Hours)	83	0	83
Annual IC Cost Burden (Dollars)	0	-12,095	12,095

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.