Information Collection

Success Case Study Interview

IC 199775 under ICR 201411-0920-009 · OMB 0920-0913.

Documents and Forms

Document Name Document Type
Success Case Study Interview Form
Success Case Study Interview Att 3i_Success Case Study.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Success Case Study Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 241

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Success Case Study Interview	Att 3i_Success Case Study.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	14	-22	36
Annual IC Time Burden (Hours)	21	-33	54
Annual IC Cost Burden (Dollars)	0	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.