Injury Website Online Survey

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1009 can be found here:

Documents and Forms

Document Name Document Type
Injury Website Online Survey Form
Injury Web Survey Intrument_genIC1009_InjuryWebSite.pdf Form
Request genIC_1009_Injury WebSite_102314.docx GenIC Request for 0920-1009 IC Document

Information Collection (IC) Details

IC Title:	Injury Website Online Survey	Agency IC Tracking Number:	15CP

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	None	Injury Web Survey	Intrument_genIC1009_InjuryWebSite.pdf	None	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
GenIC Request for 0920-1009	Request genIC_1009_Injury WebSite_102314.docx	10/23/2014

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