Information Collection

CEX - Proof of Concept Test

IC 216527 under ICR 201505-1220-002 · OMB 1220-0050.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1220-0050 can be found here:

Documents and Forms

Document Name Document Type
Attachment A1 - POC Instrument Specifications.docx Other-Instrument Specifications
Attachment A2 - Electronic Diary Screen Shots.docx Other-Diary Screenshots
Attachment A3 - Diary 2015 Inst Reqts - COVERAGE.docx Other-Instrument Requirements
Attachment 10 POC Debriefing Questions Attachment A10 - POC Respondent Debriefing Questions_final.docx Form
Attachment A - Gemini Proof of Concept Test Overview_final.docx Attachment A - Gemini Proof of Concept Test Overview IC Document
Attachment A4 - POC Advanced Letter_final.docx Attachment 4 - Advance Letter IC Document
Attachment A7 - Email Template.docx Attachment 7 _ Email Template IC Document
Attachment A11 - Analysis Plan_final.docx Attachment 11 - Analysis Plan IC Document
Attachment A5 - CE POC Debit Card Sleeve.pdf Attachment A5 - CE POC Debit Card Sleeve IC Document
Attachment A6 - Records Interview Checklist.pdf Attachment 6 - Records Interview Checklist IC Document
Attachment A9 - POC Electronic Diary video tutorial script_omb.docx Attachment 8 - POC E-Diary User Guide IC Document
Attachment A9 - POC Electronic Diary video tutorial script_omb.docx Attachment A9 - POC Electronic Diary video tutorial script IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CEX - Proof of Concept Test	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Instrument Specifications			Attachment A1 - POC Instrument Specifications.docx	Yes	Yes	Fillable Fileable
Other-Diary Screenshots			Attachment A2 - Electronic Diary Screen Shots.docx	Yes	Yes	Fillable Fileable
Other-Instrument Requirements			Attachment A3 - Diary 2015 Inst Reqts - COVERAGE.docx	Yes	Yes	Fillable Fileable
Form	Attachment 10	POC Debriefing Questions	Attachment A10 - POC Respondent Debriefing Questions_final.docx	No		Printable Only

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 450	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	1,350	1,350
Annual IC Time Burden (Hours)	1,313	1,313
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment A - Gemini Proof of Concept Test Overview	Attachment A - Gemini Proof of Concept Test Overview_final.docx	05/11/2015
Attachment 4 - Advance Letter	Attachment A4 - POC Advanced Letter_final.docx	05/11/2015
Attachment 7 _ Email Template	Attachment A7 - Email Template.docx	05/11/2015
Attachment 11 - Analysis Plan	Attachment A11 - Analysis Plan_final.docx	05/11/2015
Attachment A5 - CE POC Debit Card Sleeve	Attachment A5 - CE POC Debit Card Sleeve.pdf	05/12/2015
Attachment 6 - Records Interview Checklist	Attachment A6 - Records Interview Checklist.pdf	05/12/2015
Attachment 8 - POC E-Diary User Guide	Attachment A9 - POC Electronic Diary video tutorial script_omb.docx	05/12/2015
Attachment A9 - POC Electronic Diary video tutorial script	Attachment A9 - POC Electronic Diary video tutorial script_omb.docx	05/12/2015

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