Stakeholder Survey

CABHI Evaluation Client & Stakeholder Surveys

Documents and Forms

Document Name Document Type
Form Stakeholder Survey Stakeholder Survey Form and Instruction
Stakeholder Survey Stakeholder Survey_Wave1 Attachment 3. CABHI_Stakeholder Survey_Wave1.docx Form and Instruction
Stakeholder Survey Stakeholder Survey_Wave2 Attachment 4. CABHI_Stakeholder Survey_Wave2.docx Form and Instruction
Stakeholder Survey Stakeholder Survey_Wave3 Attachment 5. CABHI_Stakeholder Survey_Wave3.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Stakeholder Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Stakeholder Survey_Wave1	Stakeholder Survey_Wave1	Attachment 3. CABHI_Stakeholder Survey_Wave1.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Stakeholder Survey_Wave2	Stakeholder Survey_Wave2	Attachment 4. CABHI_Stakeholder Survey_Wave2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Stakeholder Survey_Wave3	Stakeholder Survey_Wave3	Attachment 5. CABHI_Stakeholder Survey_Wave3.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 780	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	Previously Approved
Annual Number of Responses for this IC	780	132	648
Annual IC Time Burden (Hours)	320	139	181
Annual IC Cost Burden (Dollars)	0	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.