Visitors and Staff

Satisfaction Surveys of Customers and Other Partners

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0458 can be found here:

Documents and Forms

Document Name Document Type
Form 3 Visitors and Staff Form and Instruction
3 Built-Adults Built Environment Survey Adult.pdf Form and Instruction
4 Built-Peds Built Environment Survey Peds.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Visitors and Staff	Agency IC Tracking Number:

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	3	Built-Adults	Built Environment Survey Adult.pdf		Yes	Yes	Paper Only
Form and Instruction	4	Built-Peds	Built Environment Survey Peds.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	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	6,500	0	0	0	0	0
Annual IC Time Burden (Hours)	1,105	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	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.