Information Collection

Prevention and Wellness Survey

IC 215718 under ICR 201503-0920-007 · OMB 0920-1079.

Documents and Forms

Document Name Document Type
Prevention and Wellness Survey Form
Survey Appendix D_AHIP Prevention and Wellness Survey_Screen Shots_FINAL_012115.doc Form
Appendix C_AHIP Prevention and Wellness Survey_FINAL_012115.doc Survey Word Document IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Prevention and Wellness Survey	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
Form	none	Survey	Appendix D_AHIP Prevention and Wellness Survey_Screen Shots_FINAL_012115.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	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	150	150
Annual IC Time Burden (Hours)	75	75
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Survey Word Document	Appendix C_AHIP Prevention and Wellness Survey_FINAL_012115.doc	03/18/2015

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