Evaluation of Efficacy of Household Water Filtration/Treatment Devices in Households with Private Wells - Household Survey Questionnaire

Evaluation of Efficacy of Household Water Filtration/Treatment Devices in Households with Private Wells

Documents and Forms

Document Name Document Type
Form None assigned Evaluation of Efficacy of Household Water Filtration/Treatment Devices in Households with Private Wells - Household Survey Questionnaire Form and Instruction
None assigned Attach 5_Scheduling Form AND Attach 6_Questionnaire: HWF 0920-0670 attachments (11-29-2006) final.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Evaluation of Efficacy of Household Water Filtration/Treatment Devices in Households with Private Wells - Household Survey Questionnaire	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	None assigned	Attach 5_Scheduling Form AND Attach 6_Questionnaire: HWFS	0920-0670 attachments (11-29-2006) final.doc		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	200	200
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.