Information Collection

PCT Web Survey Questions

IC 261650 under ICR 202307-3206-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OPM 5100 A PCT Web Survey Questions	Form and Instruction
OPM 5100 A PCT Web Survey Questions Survey Questions 5-23-23.docx	Form and Instruction
OPM 5100 A PCT Web Survey Questions Survey Questions 5-23-23.docx	Form and Instruction
Generic Clearance Submission - CX Feedback 7-28-23.docx Generic Justification	IC Document
Generic Clearance Submission - CX Feedback 7-28-23.docx Generic Justification	IC Document

IC Title:

Agency IC Tracking Number:

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 and Instruction	OPM 5100 A	PCT Web Survey Questions	Survey Questions 5-23-23.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 150,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150,000	150,000
Annual IC Time Burden (Hours)	10,000	10,000
Annual IC Cost Burden (Dollars)	12,870	12,870

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Justification	Generic Clearance Submission - CX Feedback 7-28-23.docx	08/18/2023

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