View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	TB DST Reference Center for MTBC Assessment – Online Survey	Agency IC Tracking Number:	0920-1027-17FL

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	NA	National PHL DST Reference Center for MTBC Survey	Appendix 2- Web shots TB DST Survey.docx	NA	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 24	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	24	0	24	0	0	0
Annual IC Time Burden (Hours)	4	0	4	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
NPHL DST Reference Center for MTBC Survey - WORD	Appendix 1-TB DST Survey Questions.docx	11/30/2016
Research Determination	TB DST Reference Center Project Determination_CW_ JD.pdf	11/30/2016
GenIC 0920-1027 Checklist	TB OnlineSurvey Service DeliveryChecklist.docx	11/30/2016
0920-1027 GenIC Request	Template-TB DST Survey_Online 30NOV2016.docx	11/30/2016

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