Long COVID Surveys

Clearance for A-11 Section 280 Improving Customer Experience Information Collection

Documents and Forms

Document Name Document Type
Form Long Covid Survey Long COVID Surveys Form and Instruction
Form Long Covid Survey Long COVID Surveys Form and Instruction
Long Covid Survey Long Covid Survey Wires 2023_02_10 Long Covid Survey Wires 2023_02_10.pdf Form and Instruction
Long Covid Survey Long Covid Survey Wires 2023_02_10 Long Covid Survey Wires 2023_02_10.pdf Form and Instruction
A-11 Fast-Track Clearance Request Template_Long COVID.pdf A-11 Fast-Track Clearance Request Template_Long COVID IC Document
A-11 Fast-Track Clearance Request Template_Long COVID.pdf A-11 Fast-Track Clearance Request Template_Long COVID IC Document

Information Collection (IC) Details

IC Title:	Long COVID Surveys	Agency IC Tracking Number:	Long COVID Surveys 2900-0876

IC Status: Unchanged

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	Long Covid Survey Wires 2023_02_10	Long Covid Survey Wires 2023_02_10	Long Covid Survey Wires 2023_02_10.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 22,041	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	22,041	22,041
Annual IC Time Burden (Hours)	1,837	1,837
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
A-11 Fast-Track Clearance Request Template_Long COVID	A-11 Fast-Track Clearance Request Template_Long COVID.pdf	02/15/2023

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