Information Collection

Post-clinic Survey

IC 269805 under ICR 202505-0920-004 · OMB 0920-1438.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-24CB Post-clinic Survey	Form
Form 0920-24CB Post-Clinic Visit Survey_Online_English Post-clinic Survey	Form
Form 0920-24CB Post-Clinic Visit Survey_Online_Spanish Post-clinic Survey	Form
0920-24CB Post-Clinic Visit Survey_Online_English Attachment 10h_Post-Clinic Visit Survey_Online_English.docx	Form
0920-24CB Post-Clinic Visit Survey_Online_English Attachment 10h_Post-Clinic Visit Survey_Online_English.docx	Form
0920-24CB Post-Clinic Visit Survey_Online_Spanish Attachment 10i_Post-Clinic Visit Survey_Online_Spanish.docx	Form
0920-24CB Post-Clinic Visit Survey_Online_Spanish Attachment 10i_Post-Clinic Visit Survey_Online_Spanish.docx	Form
Attachment 10m_Post-Clinic Visit Survey_Thank You Email_Spanish.docx Post-Clinic Visit Survey_Thank You Email_Spanish	IC Document
Attachment 10m_Post-Clinic Visit Survey_Thank You Email_Spanish.docx Post-Clinic Visit Survey_Thank You Email_Spanish	IC Document
Attachment 10l_Post-Clinic Visit Survey_Thank You Email_English.docx Post-Clinic Visit Survey_Thank You Email_English	IC Document
Attachment 10l_Post-Clinic Visit Survey_Thank You Email_English.docx Post-Clinic Visit Survey_Thank You Email_English	IC Document
Attachment 10k_Post-Clinic Visit Survey_Reminder Email_Spanish.docx Attachment 10k_Post-Clinic Visit Survey_Reminder Email_Spanish	IC Document
Attachment 10k_Post-Clinic Visit Survey_Reminder Email_Spanish.docx Attachment 10k_Post-Clinic Visit Survey_Reminder Email_Spanish	IC Document
Attachment 10j_Post-Clinic Visit Survey_Reminder Email_English.docx Post-Clinic Visit Survey_Reminder Email_English	IC Document
Attachment 10j_Post-Clinic Visit Survey_Reminder Email_English.docx Post-Clinic Visit Survey_Reminder Email_English	IC Document
Attachment 10g_Post-Clinic Visit Survey_Paper_English.docx Post-Clinic Visit Survey_Paper_English	IC Document
Attachment 10g_Post-Clinic Visit Survey_Paper_English.docx Post-Clinic Visit Survey_Paper_English	IC Document
Attachment 10f_Post-Clinic Visit Survey_Consent Statement_Spanish.docx Post-Clinic Visit Survey_Consent Statement_Spanish	IC Document
Attachment 10f_Post-Clinic Visit Survey_Consent Statement_Spanish.docx Post-Clinic Visit Survey_Consent Statement_Spanish	IC Document
Attachment 10e_Post-Clinic Visit Survey_Consent Statement_English.docx Post-Clinic Visit Survey_Consent Statement_English	IC Document
Attachment 10e_Post-Clinic Visit Survey_Consent Statement_English.docx Post-Clinic Visit Survey_Consent Statement_English	IC Document
Attachment 10a_Post-Clinic Visit Survey_Pre-Notification Email_English.docx Post-Clinic Visit Survey_Pre-Notification Email_English	IC Document
Attachment 10a_Post-Clinic Visit Survey_Pre-Notification Email_English.docx Post-Clinic Visit Survey_Pre-Notification Email_English	IC Document
Attachment 10b_Post-Clinic Visit Survey_Pre-Notification Email_Spanish.docx Post-Clinic Visit Survey_Pre-Notification Email_Spanish	IC Document
Attachment 10b_Post-Clinic Visit Survey_Pre-Notification Email_Spanish.docx Post-Clinic Visit Survey_Pre-Notification Email_Spanish	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Post-clinic Survey

Agency IC Tracking Number:

0920-24CB

Is this a Common Form? No

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	0920-24CB				Yes	Yes	Fillable Fileable
Form	0920-24CB				Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	300	300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Post-Clinic Visit Survey_Thank You Email_Spanish		08/02/2024
Post-Clinic Visit Survey_Thank You Email_English		08/02/2024
Attachment 10k_Post-Clinic Visit Survey_Reminder Email_Spanish		08/02/2024
Post-Clinic Visit Survey_Reminder Email_English		08/02/2024
Post-Clinic Visit Survey_Paper_English		08/02/2024
Post-Clinic Visit Survey_Consent Statement_Spanish		08/02/2024
Post-Clinic Visit Survey_Consent Statement_English		08/02/2024
Post-Clinic Visit Survey_Pre-Notification Email_English		08/02/2024
Post-Clinic Visit Survey_Pre-Notification Email_Spanish		08/02/2024

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

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