Information Collection

Demographic & Customer Satisfaction Questions (App.1A or 1 AB)

IC 219408 under ICR 202504-0925-001 · OMB 0925-0208.

Documents and Forms

Document Name Document Type
Form 1A Demographic & Customer Satisfaction Questions (App.1A or 1 AB) Form
Form 1A Customer Service and Demographic Questions Demographic & Customer Satisfaction Questions (App.1A or 1 AB) Form
Form 1AB Customer Service and Demographic Questions Demographic & Customer Satisfaction Questions (App.1A or 1 AB) Form
1A Customer Service and Demographic Questions Appendix 1A Customer Service and Demographic Questions_2025.3-5-25.docx Form
1A Customer Service and Demographic Questions Appendix 1A Customer Service and Demographic Questions_2025.3-5-25.docx Form
1AB Customer Service and Demographic Questions Appendix 1AB Customer Service and Demographic Questions_2025.3-5-25.docx Form
1AB Customer Service and Demographic Questions Appendix 1AB Customer Service and Demographic Questions_2025.3-5-25.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Demographic & Customer Satisfaction Questions (App.1A or 1 AB)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	1A	Customer Service and Demographic Questions	Appendix 1A Customer Service and Demographic Questions_2025.3-5-25.docx		Yes	Yes	Fillable Fileable
Form	1AB	Customer Service and Demographic Questions	Appendix 1AB Customer Service and Demographic Questions_2025.3-5-25.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-25-0156, âRecords of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service	FR Citation: 67 FR 60742

Number of Respondents: 15,754	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	15,754	15,754
Annual IC Time Burden (Hours)	788	788
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.

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