Early Exit Survey

Evaluation of Public Health AmeriCorps

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3045-0199 can be found here:

Documents and Forms

Document Name Document Type
Form 01 Early Exit Survey Form and Instruction
01 Member Alumni Survey and Early Exit Survey 01-Alumni and Early Exit Survey.docx MyAmeriCorps.gov Form and Instruction
01 Member Alumni Survey and Early Exit Survey 01-Alumni and Early Exit Survey.docx MyAmeriCorps.gov Form and Instruction

Information Collection (IC) Details

IC Title:	Early Exit Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	01	Member Alumni Survey and Early Exit Survey	01-Alumni and Early Exit Survey.docx	MyAmeriCorps.gov	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 443	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	443	443
Annual IC Time Burden (Hours)	443	443
Annual IC Cost Burden (Dollars)	20,980	20,980

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.