CBO Qualtrics Survey

National Hypertension Control Initiative

Documents and Forms

Document Name Document Type
Form 1 CBO Qualtrics Survey Form and Instruction
1 CBOs: Qualtrics survey Appendix B_Qualtrics and DREaM CBO quarterly survey questions_Final.docx Form and Instruction
1 CBOs: Qualtrics survey Appendix B_Qualtrics and DREaM CBO quarterly survey questions_Final.docx Form and Instruction

Information Collection (IC) Details

IC Title:	CBO Qualtrics Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 1320.8(d)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	CBOs: Qualtrics survey	Appendix B_Qualtrics and DREaM CBO quarterly survey questions_Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: National Hypertension Control Initiative - CBOs: Qualtrics survey	FR Citation: 86 FR 70510

Number of Respondents: 16	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	128	128
Annual IC Time Burden (Hours)	192	192
Annual IC Cost Burden (Dollars)	0	0

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.