TB DST Reference Center for MTBC Assessment – Online Survey

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1027 can be found here:

Documents and Forms

Document Name Document Type
TB DST Reference Center for MTBC Assessment – Online Survey Form and Instruction
National PHL DST Reference Center for MTBC Survey Appendix 2- Web shots TB DST Survey.docx Form and Instruction
Appendix 1-TB DST Survey Questions.docx NPHL DST Reference Center for MTBC Survey - WORD IC Document
TB DST Reference Center Project Determination_CW_ JD.pdf Research Determination IC Document
TB OnlineSurvey Service DeliveryChecklist.docx GenIC 0920-1027 Checklist IC Document
Template-TB DST Survey_Online 30NOV2016.docx 0920-1027 GenIC Request IC Document

Information Collection (IC) Details

IC Title:	TB DST Reference Center for MTBC Assessment – Online Survey	Agency IC Tracking Number:	0920-1027-17FL

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	NA	National PHL DST Reference Center for MTBC Survey	Appendix 2- Web shots TB DST Survey.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 24	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	24	24
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
NPHL DST Reference Center for MTBC Survey - WORD	Appendix 1-TB DST Survey Questions.docx	11/30/2016
Research Determination	TB DST Reference Center Project Determination_CW_ JD.pdf	11/30/2016
GenIC 0920-1027 Checklist	TB OnlineSurvey Service DeliveryChecklist.docx	11/30/2016
0920-1027 GenIC Request	Template-TB DST Survey_Online 30NOV2016.docx	11/30/2016

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