Injury Website Online Survey – Second request

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⚠️ Notice: This information collection may be referencing outdated material.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 – Second request Form
Website Survey Intrument_genIC1009_InjuryWebSite.pdf Form
Request genIC_1009_Injury WebSite_SecondRequest.docx Request for Approval IC Document

Information Collection (IC) Details

IC Title:	Injury Website Online Survey – Second request	Agency IC Tracking Number:	15FG

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	Website Survey	Intrument_genIC1009_InjuryWebSite.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,500	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	5,500	5,500
Annual IC Time Burden (Hours)	917	917
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval	Request genIC_1009_Injury WebSite_SecondRequest.docx	11/18/2014

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