Information Collection

Title V Information System User Satisfaction Survey

IC 264361 under ICR 202503-0906-002 · OMB 0906-0084.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Title V Information System User Satisfaction Survey	Form and Instruction
Form 1 Screen Shots of Title V Information System Survey 2021 Title V Information System User Satisfaction Survey	Form and Instruction
1 Screen Shots of Title V Information System Survey 2021 Screen Shots of Title V Information System Survey 2021.docx	Form and Instruction
1 Screen Shots of Title V Information System Survey 2021 Screen Shots of Title V Information System Survey 2021.docx	Form and Instruction
TVIS Customer Satisfaction - Supporting Statement 03092021.docx Original Generic IC request	IC Document
TVIS Customer Satisfaction - Supporting Statement 03092021.docx Original Generic IC request	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: Unchanged

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	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 70

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
	Requested	Previously Approved
Annual Number of Responses for this IC	70	70
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Original Generic IC request		01/09/2024

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

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