Document Name Document Type
Form 0920-24CB Post-clinic Survey Form
0920-24CB Post-Clinic Visit Survey_Online_English Attachment 10h_Post-Clinic Visit Survey_Online_English.docx Form
0920-24CB Post-Clinic Visit Survey_Online_Spanish Attachment 10i_Post-Clinic Visit Survey_Online_Spanish.docx Form
Attachment 10m_Post-Clinic Visit Survey_Thank You Email_Spanish.docx Post-Clinic Visit Survey_Thank You Email_Spanish IC Document
Attachment 10l_Post-Clinic Visit Survey_Thank You Email_English.docx Post-Clinic Visit Survey_Thank You Email_English IC Document
Attachment 10k_Post-Clinic Visit Survey_Reminder Email_Spanish.docx Attachment 10k_Post-Clinic Visit Survey_Reminder Email_Spanish IC Document
Attachment 10j_Post-Clinic Visit Survey_Reminder Email_English.docx Post-Clinic Visit Survey_Reminder Email_English IC Document
Attachment 10g_Post-Clinic Visit Survey_Paper_English.docx Post-Clinic Visit Survey_Paper_English IC Document
Attachment 10f_Post-Clinic Visit Survey_Consent Statement_Spanish.docx Post-Clinic Visit Survey_Consent Statement_Spanish IC Document
Attachment 10e_Post-Clinic Visit Survey_Consent Statement_English.docx Post-Clinic Visit Survey_Consent Statement_English IC Document
Attachment 10a_Post-Clinic Visit Survey_Pre-Notification Email_English.docx Post-Clinic Visit Survey_Pre-Notification Email_English IC Document
Attachment 10b_Post-Clinic Visit Survey_Pre-Notification Email_Spanish.docx Post-Clinic Visit Survey_Pre-Notification Email_Spanish IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Post-clinic Survey	Agency IC Tracking Number:	0920-24CB

Is this a Common Form? No		IC Status: Unchanged

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	0920-24CB	Post-Clinic Visit Survey_Online_English	Attachment 10h_Post-Clinic Visit Survey_Online_English.docx		Yes	Yes	Fillable Fileable
Form	0920-24CB	Post-Clinic Visit Survey_Online_Spanish	Attachment 10i_Post-Clinic Visit Survey_Online_Spanish.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 900	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	300	300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Post-Clinic Visit Survey_Thank You Email_Spanish	Attachment 10m_Post-Clinic Visit Survey_Thank You Email_Spanish.docx	08/02/2024
Post-Clinic Visit Survey_Thank You Email_English	Attachment 10l_Post-Clinic Visit Survey_Thank You Email_English.docx	08/02/2024
Attachment 10k_Post-Clinic Visit Survey_Reminder Email_Spanish	Attachment 10k_Post-Clinic Visit Survey_Reminder Email_Spanish.docx	08/02/2024
Post-Clinic Visit Survey_Reminder Email_English	Attachment 10j_Post-Clinic Visit Survey_Reminder Email_English.docx	08/02/2024
Post-Clinic Visit Survey_Paper_English	Attachment 10g_Post-Clinic Visit Survey_Paper_English.docx	08/02/2024
Post-Clinic Visit Survey_Consent Statement_Spanish	Attachment 10f_Post-Clinic Visit Survey_Consent Statement_Spanish.docx	08/02/2024
Post-Clinic Visit Survey_Consent Statement_English	Attachment 10e_Post-Clinic Visit Survey_Consent Statement_English.docx	08/02/2024
Post-Clinic Visit Survey_Pre-Notification Email_English	Attachment 10a_Post-Clinic Visit Survey_Pre-Notification Email_English.docx	08/02/2024
Post-Clinic Visit Survey_Pre-Notification Email_Spanish	Attachment 10b_Post-Clinic Visit Survey_Pre-Notification Email_Spanish.docx	08/02/2024

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

Post-clinic Survey