Information Collection

Demographic & Customer Satisfaction Questions (App. 9)

IC 219411 under ICR 202504-0925-001 · OMB 0925-0208.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Demographic & Customer Satisfaction Questions (App. 9)	Form
Form 1 Customer Service and Demographic Questions Demographic & Customer Satisfaction Questions (App. 9)	Form
1 Customer Service and Demographic Questions Appendix 9 Customer Satisfaction Survey Questions.docx	Form
1 Customer Service and Demographic Questions Appendix 9 Customer Satisfaction Survey Questions.docx	Form

IC Title:

Agency IC Tracking Number:

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	1				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 67042

Number of Respondents: 400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].