[NCIPC] Three-Month Survey: Module WB4518, Talking about Naloxone

[OADC] CDC Usability and Digital Content Testing

Documents and Forms

Document Name Document Type
[NCIPC] Three-Month Survey: Module WB4518, Talking about Naloxone Form and Instruction
Talking about Naloxone survey Att. 3_Three-Month Survey Instrument_Module WB4518, Talking about Naloxone.docx Form and Instruction
Att. 1_OMB Privacy Determination_Three-Month Survey_Module WB4518, Talking about Naloxone-Collection of Routine Customer Feedback (002).pdf Privacy Assessment IC Document
Att. 4_Screenshots_ Three-Month Survey_Module WB4518, Talking about Naloxone_.docx Survey Screenshots IC Document
Att. 2_1050_GenIC_Request Template Service Delivery_ Three Month Survey_Module WB4518 Talking about Naloxone.docx GenIC Request Template IC Document

Information Collection (IC) Details

IC Title:	[NCIPC] Three-Month Survey: Module WB4518, Talking about Naloxone	Agency IC Tracking Number:	0920-1050-24DW

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 and Instruction	n/a	Talking about Naloxone survey	Att. 3_Three-Month Survey Instrument_Module WB4518, Talking about Naloxone.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Privacy Assessment	Att. 1_OMB Privacy Determination_Three-Month Survey_Module WB4518, Talking about Naloxone-Collection of Routine Customer Feedback (002).pdf	03/21/2024
Survey Screenshots	Att. 4_Screenshots_ Three-Month Survey_Module WB4518, Talking about Naloxone_.docx	03/21/2024
GenIC Request Template	Att. 2_1050_GenIC_Request Template Service Delivery_ Three Month Survey_Module WB4518 Talking about Naloxone.docx	03/21/2024

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