Information Collection

Participant Feedback Form

IC 201611 under ICR 202601-0930-001 · OMB 0930-0270.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Participant Feedba Participant Feedback Form	Form and Instruction
Form Participant Feedba Participant Feedback Survey Form Participant Feedback Form	Form and Instruction
Participant Feedba Participant Feedback Survey Form Attach F dtac-ccp-toolkit-participant-feedback-survey.pdf	Form and Instruction
Participant Feedba Participant Feedback Survey Form Attach F dtac-ccp-toolkit-participant-feedback-survey.pdf	Form and Instruction

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 and Instruction	Participant Feedback Survey Form				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Participant Feedback Form

FR Citation: 75 FR 28264

Number of Respondents: 4,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	4,000	4,000
Annual IC Time Burden (Hours)	1,200	1,200
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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