Customer Focus Group Screener

Health Hazard Evaluation Program Customer Survey

Documents and Forms

Document Name Document Type
Form no number Customer Focus Group Screener Form
no number Focus Group Screener Attachment D Focus Group Screener.doc Form

Information Collection (IC) Details

IC Title:	Customer Focus Group Screener	Agency IC Tracking Number:

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	no number	Focus Group Screener	Attachment D Focus Group Screener.doc		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 216	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	216	216
Annual IC Time Burden (Hours)	54	54
Annual IC Cost Burden (Dollars)	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.