Information Collection

Exit Survey Part 2

IC 249047 under ICR 202505-0925-001 · OMB 0925-0772.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Exit Survey Part 2	Form
Form 1 Survey Exit Survey Part 2	Form
1 Survey Data Collection Instrument - Exit Survey Part 2.docx	Form
1 Survey Data Collection Instrument - Exit Survey Part 2.docx	Form

IC Title:

Exit Survey Part 2

Agency IC Tracking Number:

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	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 09â25â0014, âClinical Research; Student Records, HHS/PHS/NIH/OD/OIR/OE.â

FR Citation: 67 FR 67042

Number of Respondents: 150

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	Previously Approved
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	50	50
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.

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