Information Collection

CureTB Partner Feedback (Satsifaction Assessment) Questionnaire 2

IC 252225 under ICR 202402-0920-003 · OMB 0920-1186.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1186 CureTB Partner Feedback (Satsifaction Assessment) Questionnaire 2	Form and Instruction
Attachment A2.a. – Supplemental CureTB Program Partner Satisfaction Assessment Questionnaire 2.pdf	Other-Questionnaire annotated with s
Attachment A2.a. – Supplemental CureTB Program Partner Satisfaction Assessment Questionnaire 2.pdf	Other-Questionnaire annotated with s
0920-1186 CureTB Partner Feedback Att. G- Questionnaire 2 - Online Survey Preview-no skip logic.pdf	Form and Instruction
0920-1186 CureTB Partner Feedback Att. G- Questionnaire 2 - Online Survey Preview-no skip logic.pdf	Form and Instruction
Att. K-CureTB Referral Outcome Notification form.pdf CureTB Referral Outcome Notification	IC Document
Att. K-CureTB Referral Outcome Notification form.pdf CureTB Referral Outcome Notification	IC Document

IC Title:

Agency IC Tracking Number:

0920-1186

Is this a Common Form? No

IC Status: Modified

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	0920-1186	CureTB Partner Feedback	Att. G- Questionnaire 2 - Online Survey Preview-no skip logic.pdf		Yes	Yes	Fillable Fileable
Other-Questionnaire annotated with skip logic			Attachment A2.a. â Supplemental CureTB Program Partner Satisfaction Assessment Questionnaire 2.pdf		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	50	0	50
Annual IC Time Burden (Hours)	5	0	5
Annual IC Cost Burden (Dollars)	0	-223	223

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CureTB Referral Outcome Notification	Att. K-CureTB Referral Outcome Notification form.pdf	02/21/2024

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