Information Collection

Pactice- and Systems-Level Change Survey Sampling Form

IC 223977 under ICR 201610-0970-006 · OMB 0970-0495.

Documents and Forms

Document Name Document Type
Form 1 Pactice- and Systems-Level Change Survey Sampling Form Form and Instruction
1 Practice and Systems Level Change Survey Sampling Form Practice and Systems Level Change Survey Sampling Form (4).docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pactice- and Systems-Level Change Survey Sampling Form	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 and Instruction	1	Practice and Systems Level Change Survey Sampling Form	Practice and Systems Level Change Survey Sampling Form (4).docx		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	14	14
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	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.