Exam Clinic 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⚠️ Notice: This information collection may be referencing outdated material.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 1405-0193 can be found here:

Documents and Forms

Document Name Document Type
Exam Clinic Survey.pdf Other-Survey: SV-2018-0008
Generic Clearance Submission Survey Template - SV-2018-0008.pdf Generic Clearance Submission Survey Template IC Document

Information Collection (IC) Details

IC Title:	Exam Clinic Survey	Agency IC Tracking Number:

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
Other-Survey: SV-2018-0008			Exam Clinic Survey.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,080	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	1,080	1,080
Annual IC Time Burden (Hours)	90	90
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Generic Clearance Submission Survey Template	Generic Clearance Submission Survey Template - SV-2018-0008.pdf	10/24/2018

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