Information Collection

Questionnaire - Community Leaders

IC 206656 under ICR 201304-0920-014 · OMB 0920-0988.

Documents and Forms

Document Name Document Type
Attachment C - CDC Questionnaire.docx Other-WORD
Attachment G - CDC screenshots 2013.pdf Screenshots IC Document
Attachment F - Email invitation letter.doc E-mail Invitation IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Questionnaire - Community Leaders	Agency IC Tracking Number:

Is this a Common Form? No		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-WORD			Attachment C - CDC Questionnaire.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Screenshots	Attachment G - CDC screenshots 2013.pdf	04/23/2013
E-mail Invitation	Attachment F - Email invitation letter.doc	04/23/2013

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