Information Collection

Survey

IC 248417 under ICR 202107-0920-003 · OMB 0920-1359.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1359 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-21DC Survey Form and Instruction
0920-21DC Survey Year One Attachment 7_Survey_Year 1.docx Form and Instruction
0920-21DC Survey Year One Attachment 7_Survey_Year 1.docx Form and Instruction
0920-21DC Survey Year Two/Three Attachment 8_Survey_Year 2 and 3.docx Form and Instruction
0920-21DC Survey Year Two/Three Attachment 8_Survey_Year 2 and 3.docx Form and Instruction
Attachment 10_ Screenshots of Survey_Y1.pdf Screenshots Survey Year One IC Document
Attachment 10_ Screenshots of Survey_Y1.pdf Screenshots Survey Year One IC Document
Attachment 11_Screenshots of Survey_Y2-3.pdf Screenshots Survey Year Two/Three IC Document
Attachment 11_Screenshots of Survey_Y2-3.pdf Screenshots Survey Year Two/Three IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey	Agency IC Tracking Number:	0920-21DC

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-21DC	Survey Year One	Attachment 7_Survey_Year 1.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-21DC	Survey Year Two/Three	Attachment 8_Survey_Year 2 and 3.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 480	Number of Respondents for Small Entity: 300

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	480	480
Annual IC Time Burden (Hours)	280	280
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Screenshots Survey Year One	Attachment 10_ Screenshots of Survey_Y1.pdf	07/16/2021
Screenshots Survey Year Two/Three	Attachment 11_Screenshots of Survey_Y2-3.pdf	07/16/2021

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